Biocompatible intermittent hemodialysis

Since intermittent hemodialysis was first used systemically during the Korean war, the mortality of acute renal failure (ARF) in critically ill patients has remained high ( > or 50%). The lack of improvement may be a result of better resuscitation techniques and intensive care management that allow more severely ill patients to survive long enough to develop ARF. The concept that those patients with ARF die with, but not of, renal failure was challenged recently by the results of three prospective randomized trials. Each tested the hypothesis that the course of ARF and the fate of critically ill patients may be affected adversely by bioincompatibility reactions due to the dialysis membrane used (activation of complement and neutrophils). Schiffl and colleagues were the first to publish a full report on the results of their investigation comparing bioincompatible cuprophane (CUP) and biocompatible acrylonitrile AN 69 (Hospal, Lyon, France) membranes in 52 patients with ARF following cardiovascular surgery. The AN 69 group had a lower death rate (38% vs. 65%, p = 0.052), a lower proportion of patients dying from Gram-negative sepsis (40% vs. 71%, p = 0.0162), and an improved recovery of renal function. A similar trial comparing the use of CUP with biocompatible polymethyl-methacrylate (PMMA) was performed in 72 patients with medical categories of ARF. Again, the use of a biocompatible membrane resulted in an improved survival rate (57% vs. 37%, p = 0.11) and better recovery of renal function (62% vs. 37%, p = 0.04). Of the 20 patients in each group who initially had nonoliguric ARF, the survival rates were 80% with PMMA and 40% with CUP (p = 0.01). The preliminary results of another multicenter study including 121 patients dialyzed with either bioincompatible cellulosic membranes or PMMA or polysulfone membranes seem to confirm these findings. The management of critically ill patients is sophisticated and expensive. The use of biocompatible membranes adds little to the overall costs and appears to be justified.