INTRODUCTION
Acute renal failure is a clinical syndrome characterized by high mortality. There have been numerous attempts to improve survival in this condition, such as the use of drugs, vasoactive medication, biocompatible membranes, high flux, etc. Nevertheless, mortality remains high Citation[1-2a], Citation[2b-4]. Some promising preliminary results in this field have already been published by our team Citation[5-6]. ARF is on the one side mostly a part of MOF and rare independent clinical event. As has been previously documented, the greater the number of organ systems involved in MOF the higher the mortality rate. In a randomized prospective study we tried to answer whether biocompatibility, or high flux, or both, have any effect on survival of dialysis dependent patients with multiple organ failure.
PATIENTS AND METHODS
Patients with acute renal failure aged over 18 years treated in the intensive care units of cardiac surgery department, of general surgery department, and of the department of medicine, were enrolled in the prospective, randomized study. Severity of clinical condition was expressed by APACHE II0, 1, 2, 3, 4, 7, 14, 21 score, recorded on specific days after the inclusion Citation[7-8]. Since the majority of patients had multiple organ failure, Marschal score was also calculated Citation[[9]]. Hemodialysis was instituted using bicarbonate dialysis, on the machine with controlled volumetric ultrafiltration. Membranes MCA 130 (acetate cellulose membrane), Fresenius F60 (polysulfonic membrane), Altraflux (modified cellulose diacetate membrane), and Fresenius F6 (polysulfonic membrane), were used. Membrane MCA 130 has properties of low flux bioincompatible membrane, F60 of high flux biocompatible membrane, Altraflux of high flux poorly compatible membrane, and F6 of low flux biocompatible membrane.
Results were statistically analyzed using analysis of variance for survival.
RESULTS
Results are presented in tables.
Table 1. Frequency of Multiple Organ Failure/ARF According to Diagnoses
Table 3. Severity of Clinical Condition at Inclusion in the Study of Survival of MOF/ARF Patients
Table 4. Survival of Patients with MOF/ARF Dialyzed Using Different Membranes
Table 5. Survival of Patients with MOF/ARF Dialyzed Using BC/High Flux Compared to BIC/Low Flux Membrane
Table 6. Survival of Patients with MOF/ARF Dialyzed Using BC/high Flux Compared to BIC/Low Flux Membrane
Table 7. Survival of Patients Dialyzed Using the Same Type of Membrane with Different Flux
Table 8. Effect of Age on Survival in Multiple Organ Failure
Table 9. Effect of Sex on Survival in Patients with MOF
DISCUSSION
Acute renal failure as a clinical syndrome in hospitals most frequently occurs in conjunction with major surgeries, and as a consequence of sepsis. Almost as a rule, the kidney is just one of the failing organs, and organ system failures (respiration, circulation, coagulation) fundamentally affect the outcome. These are main reasons why assessment of place and role of one of the supportive systems is complex and difficult. The idealized notion, that biocompatible membranes invariably improve survival of patients with renal failure associated with multiple organ failure, has no firm foundations Citation[10-11]. The fact that there are low flux membranes and high flux membranes also hinders data analysis. However, from previous studies and results of our prospective randomized study some answers can be discerned. In our study, comparing biocompatibililty and high flux on one hand, and bioincompatibility and low flux on the other, we have not obtained statistically significant difference in survival. Because of better survival in BC/high flux group compared to the BIC/low flux group we extended number of patients to 46, (the same inclusions criteria, APACHE II0 scores NS) and reached statistically significant difference.
In the analysis of one type of biocompatible membrane (polysulfon) with low and high flux we found no difference in survival. These results indicate that flux per se has less significance than the quality of the membrane. In the analysis of different membranes we did not obtain convincing statistical significance in survival. This suggests that if there are differences in survival they are small, which explains numerous contradictory results of the studies published up to now Citation[12-15]. One must also recognize that the survival is dependant upon the treatment of multiple organ failure and not the treatment of ARF alone. In addition age is certainly a predictor of survival. The results published up to now, even if contradictory, point to the importance of high flux biocompatible membranes. However, they also show continuing high mortality due to multiple organ failure. These data emphasize the necessity of prevention of septic events whenever possible, control of circulating volume and avoidance of dehydration, monitoring of concentration of nephrotoxic drugs and re-evaluating the indications for their administration Citation[16-17]. Permanent and meticulous supervision of the mentioned parameters would at least partly reduce the number of patients who develop acute renal failure, in view of the fact that novel techniques have only a minor effect on survival. Answer to the question whether the use of new biocompatible and high flux membranes in the management of patients with multiple organ failure represents an advance, or is it just rumor, is not simple or conclusive. There seems to be an moderate effect on survival, but only if comparison is made between use of biocompatible high flux membranes and the use of bioincompatible low flux membranes. The etiology of multiple organ failure is crucial. Acute renal failure is usually a part of multiple organ failure and survival in this condition depends on the number of organs in failure. This could explain the modest results and contradictory conclusions while using different biocompatible membranes in very severe clinical conditions Citation[18-21].
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