A COMPARISON OF CONVENTIONAL DIALYTIC THERAPY AND ACUTE CONTINUOUS HEMODIAFILTRATION IN THE MANAGEMENT OF ACUTE-RENAL-FAILURE IN THE CRITICALLY ILL

Objective: To compare and contrast the clinical outcomes in critically ill patients with acute renal failure managed with either acute conti nuous hemodiafiltration or conventional dialytic therapies. Design: Re trospective review of the medical records of 167 consecutive cases of acute renal failure treated at a single center (July 1982-July 1991). Scoring for illness severity (APACHE II, number of failing organs) and assessment of outcome in terms of biochemical control of azotemia, AR F therapy-related morbidity, and overall morbidity and mortality. Sett ing: Tertiary institution. Patients: 167 consecutive critically ill pa tients with multiorgan failure and acute renal failure. Measurements a nd Main Results: 84 patients received conventional dialytic therapy (C DT) (1982-1988) and 83 acute continuous hemodiafiltration (ACHD) (1988 -1991). The etiology of ARF and illness severity indices were similar in both groups (organ failure scores: CDT 3.9 vs. ACHD 4.1; NS). All p atients were critically ill, with more severely ill patients within th e ACHD groups (mean APACHE II score: CDT 25.8 vs. ACHD 28.1; p < .01). There were no significant differences in pretreatment serum creatinin e, glucose, bicarbonate and phosphate, white cell and platelet counts, incidence of disseminated intravascular coagulation, prevalence of se psis, or evidence of pulmonary and/or peripheral edema. Overall surviv al was 29.8% for the CDT groups and 41% for the ACHD group (NS). When patients were stratified by severity of illness, survival in those wit h 2 to 4 failing organs was significantly greater in the ACHD group (C DT 31.1% vs. ACHD 53.8%; p < .025). Similarly, overall survival in pat ients with intermediate APACHE II scores (24 to 29) was significantly better in those treated with ACHD (CDT 12.5% vs. ACHD 46.4%; p < .025) . During the course of ARF, in comparison to CDT, ACHD was associated with greater overall reductions in serum creatinine, and in phosphate and plasma urea, and an increased net nutritional intake. Conclusions: ACHD provided biochemical and outcome indicator advantages over conve ntional dialytic therapy. In patients with 2 to 4 failing organs or an intermediate APACHE II score (24 to 29) a significant survival advant age was demonstrated for ACHD over CDT. Although this study is a retro spective analysis, with all the inherent limitations of such studies, it suggests that ACHD is the treatment of choice for ARF in the critic ally ill, with maximum benefits seen in those with 2 to 4 failing orga ns and/or intermediate APACHE II scores.