Technical advances in renal replacement therapy

Abstract

Critically ill patients are subject to several risk factors for organ injury: surgical intervention, trauma, rhabdomyolysis, hemodynamic instability, organ hypoperfusion, bacteremia and endotoxemia, sepsis and septic shock. These conditions may cause acute kidney injury (AKI), myocardial dysfunction, liver failure, coagulation abnormalities, acute lung injury (ALI), adult respiratory distress syndrome (ARDS), bone marrow depression, loss of acid/base homeostasis, and finally, brain dysfunction. The resulting picture of multiple organ dysfunction syndrome (MODS) is a lethal clinical entity that is refractory to all therapies in the majority of cases. According to the "humoral theory of sepsis", soluble substances circulate in blood and participate in the generation of the different disorders of MODS; thus, AKI is not the only clinical disorder observed in intensive care unit (ICU) patients nor is it an isolated syndrome. Current extracorporeal management of such patients focuses mainly on renal replacement therapy (RRT). Nevertheless, in recent years, technical evolution of extracorporeal devices led to the potential creation of multiple organ support therapy (MOST) in order to provide a comprehensive replacement of multiorgan dysfunction: hence, other organs (liver, heart, lungs) and syndromes (abdominal sepsis, septic shock) can today be consistently supported and bridged. The technical advances of extracorporeal equipment, moreover, might allow today the design of a dedicated pediatric RRT device in order to treat patients below 10 kg, with the safety and adequacy standards that are currently granted to the adult population. This review will describe the technical evolution of MOST machines and current literature available on MOST.