40 Years of Continuous Renal Replacement Therapy. Группа авторов
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Название: 40 Years of Continuous Renal Replacement Therapy
Автор: Группа авторов
Издательство: Ingram
Жанр: Медицина
Серия: Contributions to Nephrology
isbn: 9783318063073
isbn:
From Renal Replacement to Multiple Organ Support Therapy
The effect of different modalities of CRRT on length of stay and recovery of renal function in the general population is still under evaluation since the case mix is changing in every study and the population treated is not homogeneous. In this field, further research is needed, although it has become evident that precision CRRT (personalized prescription) should be adopted in order to optimize results in single patients even in the absence of documented benefits of one specific technology for the general population. Adequate technological support becomes mandatory to fulfil all these expectations, and a generation of new machines and devices has been made compatible with the demand for increased efficiency, accuracy, safety, performance, and cost/benefit ratio. At present, almost all CRRT therapies can be delivered in a safe, adequate, and flexible way, thanks to devices being specifically designed for critically ill patients. The development is a point where multiple organ support therapy is envisaged as a possible therapeutic approach in the critical care setting. In this way, the CRRT machine becomes a platform for multiple organ support via extracorporeal therapies carried out with specific biomaterials and devices [28].
A last comment should be dedicated to the use of sorbents and especially those cartridges dedicated to the adsorption of endotoxin and related material. A great deal of evolution has occurred in this field and it seems we are gathering enough experience and evidence to suggest these therapies in specific patients with postsurgery abdominal septic shock [29, 30].
Fig. 1. Latest generation continuous RRT (CRRT) machines available on the market today.
Latest Generation of CRRT Machines
The latest generation of machines available on the market today and representing the evolution of the past 4 decades of research and development is shown in Figure 1. Specific machines have now been designed to permit safe and reliable performance of the therapy. These new devices are equipped with a user-friendly interface that allows for easy performance and monitoring. The apparent complexity of the circuit is made simple by a self-loading circuit or a cartridge, which includes the filter and the blood and dialysate lines. Priming is performed automatically by the machine, and pre- or post-dilution (reinfusion of substitution fluid before or after the filter) can be easily performed by changing the position of the reinfusion line. These new machines permit all CRRT techniques to be performed by programming the flows and the total amounts of fluid to be exchanged or circulated as a countercurrent dialysate throughout the session.
Fig. 2. The impact of technology in the process of prescription and delivery of continuous RRT (CRRT; reproduced with permission from [39], www.adqi.org).
Innovation and Consensus on CRRT Technology Requirements
The 17th Acute Disease Quality Initiative consensus conference held in Asiago during the period June 10–13, 2016, set the stage for the most important required innovation in CRRT technology and the most important recent developments in this field [31].
First of all there was a call to action inviting all experts and manufacturers in the field of CRRT technology to utilize a standardized nomenclature [32–34]. This is considered the fundamental starting point to generate common knowledge and to advance in a homogeneous environment.
The consensus group focused on future technological needs and expected advances, pointing out the desirable characteristics of new equipment and membranes, and the importance of integration of information technology in the process of patient care and decision making. Some conclusions were made based on current available evidence and some statements were mostly based on expert opinion and a proposed future research agenda [35].
Throughout AKI management, technology is involved at different levels and contributes to improve practice and patient outcomes by supporting prescription and delivery of CRRT (Fig. 2).
AKI management is a continuum from detection to treatment, which must include continuous reevaluation of treatment prescription and delivery. The use of modern information technology tools was recommended to improve practice and patient care. The process of patient evaluation and identification of therapy targets should lead to a “precision” (personalized) prescription according to patient needs and desired physiological targets. The concept of a gap between capacity (of the native organ) and (metabolic) demand is emerging as an important element to prescribe personalized therapy. In the process of dynamic prescription (frequently adjusted on the basis of actual delivery results), full-treatment reassessment should be made at least every 6 h while dedicated equipment (CRRT machines) should be used to deliver specific techniques. Adoptive technologies should be avoided. When prescribing CRRT, availability, training, and environmental and staffing issues should be considered, and prescription should be made according to local conditions and usage. Several technological tools have been developed to monitor target achievement and to suggest modifications in prescription. Manual, authorized, or automatic feedback technology is now available in chronic dialysis machines and it should be promoted in future CRRT machines. Integration of patient and machine signals through information technology tools and connectivity with EMR and data collection systems will be required to allow pragmatic trials and to make big data registries available for analysis. Data can then be used for QA and CQI purposes in the center, in the region, and even in multinational data collection studies.
Different surface and structure modifications have been introduced on new membranes to increase biocompatibility, reduce thrombogenicity, and to modify sieving and adsorption properties. Surface functionalization has also been attempted as in the case of vitamin E-bound membranes, where α-tocopherol has been covalently bound to a polysulfone membrane to reduce oxidant species generation and oxidant stress, to prevent or treat ischemia-reperfusion injury, and to improve the inflammatory pattern in sepsis [36]. These membranes should be further investigated.
The nature of the critically ill patient requires a continuous control of CRRT delivery and strict adherence to prescription, СКАЧАТЬ