Gastaldello K, Melot C, Vanherweghem JL, Kahn RJ, Tielemans C
Cellulose diacetate does as well as polysulfone for the treatment of
acute renal failure in the intensive care unit
Am Soc Nephrol
J Am Soc Nephrol (abstract)
(Sep) 7:1447 1996
Also reviewed: Biocompatibility of dialyzer membranes in important in
the outcome of acute renal failure. M Assouad, S Tseng, K Dunn, J
Gonzalez, S Brennan, W Suki. JASN 7:1437, 1996.
Ray Hakim has data that biocompatibility favorably impacts hospitalization
and infection in chronic renal failure. If the mechanism is related to an
improved cytokine response, then it is intuitively reasonable that
biocompatibility should have an impact on the outcome of acute renal
failure. Infection remains an important cause of morbidity and mortality
in acute renal failure. The mortality of acute renal failure remains high
inspite of successful renal replacement therapy. Unless biocompatibility
mechanisms directly effect the mechanism of the underlying disease, it is
hard to see how gradations of biocompatibility could have an impact on
outcome detected in small studies.
I. Gastaldello and colleagues randomly assigned patients (after
stratification for severity by Apache II) to cellulose diacetate,
polysulfone (non high flux), or polysulfone (high flux). There were no
differences in survival (37% to 51%) or in days ( about 9 days) to renal
recovery. There were no demographic or severity differences among the
three groups. The authors argue for the "cost effectiveness" of the least
expensive membrane.
II. Assouad and colleagues randomized 51 patients to either polymethyl
methacrylate or cellulose acetate. The Apache III scores and demographics
were the same. There were no differences in recovery rate, transition to
ESRD, death (36% and 42%), conversion to oliguria, or the number of days
requiring dialysis support (11 and 16) between the two groups.
Comment: Until these studies are published it will not be clear to
what extent they
have answered the question of biocompatibility's contribution to renal and
patient survival. It is hard to believe that in the context of the cost of
ICU care that the 20$ to 30$ difference in dialyzer cost would even show up
on the final bill. The argument in favor of one or the other membranes has
to be based on pathophysiology. It is unlikely that either study was
powered to show the difference that biocompatibility might make. Given the
multvariate model that likely describes survival in ARF, the correlation
due to the membrane is going to be a small part of the total regression.
(Peter B. DeOreo MD, Case Western Reserve University, Cleveland)
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Am Soc Nephrol
Basic hemodialysis :
(Intermittent) dialysis for ARF
Basic hemodialysis :
Dialyzers