ICU

(blood purification)ICU(renal replacement therapy, RRT)

70RRT30RRT()RRT

RRTICUICU

Delphi(1)1999120093MedlineEvidence-Based Medicine Reviews (EBMR)Lippincott Williams & Wilkins (LWW)4hemofiltrationdialysisrenal replacement therapycontinuous renal replacement therapycritical illnessacute renal failure

Delphi

A

2

B

1

C

D

1

E

/

RRThemoperfusionHPplasma exchangePERRTHPPERRT

RRT

RRT[1]hemodialysisHDhemofiltrationHFhemodiafiltrationHDFHDHFHDFRRT[2,3]5mmol/L)[19][]

HCO3-RRTHCO3-100 mmol/h[20][]

HCO3-RRTHCO3-RRT[21][]

2

RRT[B]

CRRTPANPSPA(PMMA)PC

PA[22][]IL-6IL-1[23][]

3

[C]

CRRTPAN[24][]32PMMA24[25, 26][]RRT

RRTCRRT5 00010 000 IU/L()112 000 IU/L10 000 IU/L[28][]

[28][][29][]

4

CRRT[C]

()()[30][][31][][32][]

RRT

CRRT2APTT>60s24 hRRT

530 ku11.5h[33][34](heparin-induced thrombocytopenia,HIT)AT

1.2 0005 000 IU500-2 000 IU/h[35]2530 IU/kg510 IU/kgh[36, 37]46 hAPTTAPTT11.4[38]

5

RRT,APTTACT[E]

2.[39][][30]10001666IU/h1mg :100IUACT>250sACT309mol/LRRT[58][]BUNRRTn=100BUN 15 mmol/LRRTBUN 43 mmol/LRRT(39% vs 20%)RRT,[59][]5RRTCRRT[60]

RRTBUNCr

8

RRT[D]

2.

ICURRTCVVHCVVHDCVVHDFIHD

ARFCVVHARFIHD[61][]CVVHIHD[62][]Augustine80ARFRCTCVVHDIHD[63][]3CRRTMehtaCVVHDFIHDCVVHDF(92.3%)IHD(59.4%)CVVHDFIHD(44.7%)IHDCVVHDF(6.7%)[64][]JackaCVVHDF(87.5%)IHD(35.7%)[65][]286090ICUCVVHDFIHD[66][]

2002Kellum[67][]CRRTARFCRRTIRRT6CRRTTonelliCRRTIRRT[68][]20073CRRTIRRTARF[69-71][]

CRRTIRRTARFCRRTIRRTICUARFCRRT

CRRTIRRTCVVHIHDCVVHDFIHDCRRTIRRTCRRTIRRT

9

ARFCRRT[D]

(Slow extended daily dialysis/sustained low-efficiency dialysis, SLED)2004KumarSLEDCVVHD[15, 72]SLEDCVVHDSLED

3.

CVVHCVVHDFIHD

CVVHCVVHDFIHD

(1)CVVH

Ronco425ARFRCTCVVH20 ml/kg/h35 ml/kg/h45 ml/kg/h 320 ml/kg/h2ARFCVVH35ml/kg/h[4][]RCT11ARFCVVH6L/h[73]ARF35ml/kg/hCVVH

CVVH35

10

ARFCVVH35ml/kg/h[B]

(2)CVVHDF

CVVHDFCVVH

206ARFRCTCVVH(1-2.5L/h,25ml/kg/h)1-1.5L/hCVVHDF(42ml/kg/h)2890CVVH[75][I]2008RCT(1124)(35.8ml/kg/h)60(22ml/kg/h)(51.2% vs 48%)RRTIHDCVVHDFSLED[76][I]Tolwani(200)CVVHDF35ml/kg/h30(49%)20ml/kg/h(56%)(69%)(80%)[77][]CVVHDF

(3)IHD

Kt/VKtV[6]146RCT[78][I]IHDIHDIHD35 ml/kg/hCVVHIHD1.4 Kt/V/day[7]IHDARF

IHD

[79-81]RCT[82]2002Ronco C[74][]CVVHARF80RCT[83][](25ml/kg/h)CVVHCVVHCVVHHVHF20(APACHE IISOFA)[84]]CVVHDFTNF-alphaIL-1 betaIL-6IL-8[85][]Bellomo[86, 87]HVHFMOF[79, 88]

HVHF

RRT

336hCVVH(35 ml/kg/h)6h HVHF(100 ml/kg/h)HVHFIL-6IL-1SOFACVVH[89][][84][]HVHF12HVHF20(APACHE IISOFA)HVHFCVVH[90][]RRTHVHF[86, 87]MOF[79]

HVHF

RRT

100 mL/kg/hSOFA35 mL/kg/h[89][]20(>0.3g /kg/ min)12HVHF(100ml/kg/h)pH[84][]100ml/kg/h300ml/min80[80][]6HVHF(45ml/kg/h)CVVH28ICU35L/4 h[87][]40-60ml/kg/h[86]85ml/kg/h(6~8h HVHFCVVH 16-18)[79][]100ml/kg/h(12h)[84]

HVHF45ml/kg/h100ml/kg/h

45-100.

11

HVHF45ml/kg/h[D]

severe acute pancreatitis,SAPsystemic inflammatory response syndrome,SIRS

SAPSAP

20RCT[91][]72APACHE>84-12h(P50ml/kg/h48~96[99][]

ml/kg/h

14

SAP[D]

SIRS29CVVH(12)(14)IL-6(P