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Critères de début et d’arrêt de l’épuration extrarénale en réanimation

Criteria to start and stop renal replacement therapy in intensive care unit

  • Session Thématique
  • Published:
Réanimation

Résumé

Les critères d’initiation et d’arrêt de l’épuration extrarénale (EER) en cas d’insuffisance rénale aiguë font l’objet d’intenses débats. L’hyperkaliémie menaçante, l’oedème pulmonaire de surcharge générant une hypoxémie sévère et les complications de l’hyper-urémie (péricardite et encéphalopathie) sont les seuls critères indiscutables d’EER en urgence. En dehors de ces situations, deux stratégies peuvent se discuter : 1) une stratégie d’EER précoce, qui a pour but de mieux contrôler les désordres métaboliques, mais qui expose à des risques tels que ceux liés aux cathéters et à la circulation extracorporelle ; 2) une stratégie d’attente, qui permet de minimiser ces risques. Les études françaises AKIKI et IDEAL-ICU ont pour objectif de démontrer quelle stratégie est la meilleure.

Une fois l’EER initiée, il faut évaluer quotidiennement l’intérêt de son maintien et envisager son sevrage. L’évaluation de la fonction rénale est très complexe une fois l’EER débutée. La reprise d’une diurèse est, en l’état actuel de la connaissance, l’élément le plus prédictif de la reprise de la fonction rénale.

Abstract

Timing of renal replacement therapy (RRT) and criteria for stopping it in acute kidney injury are hot topics. Life-threatening hyperkalemia, acute overload pulmonary edema generating severe hypoxemia and uremic complications (pericarditis and encephalopathy) are the only indisputable emergency RRT criteria. Apart from these situations, two strategies can be discussed: 1) An early RRT strategy allows better control of metabolic disorders but exposes patients to potential adverse effect among which the complications associated with catheter and extracorporeal circulation; 2) A delayed strategy to minimize these risks. The French studies AKIKI and IDEAL-ICU are intended to solve this question.

Once RRT is started, its usefulness should be appreciated daily and clinician should consider its discontinuation as soon as possible. Assessment of renal function during RRT is difficult. In the current state of knowledge, urine output is the best predictor of renal function recovery.

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Authors and Affiliations

  1. service de réanimation médicochirurgicale, AP-HP, hôpital Louis Mourier, 178 rue des Renouillers, F-92110, Colombes, France

    S. Gaudry, N. Zucman & D. Dreyfuss

  2. Sorbonne Paris Cité, ECEVE, UMRS 1123, Univ Paris Diderot, F-75010, Paris, France

    S. Gaudry

  3. INSERM, ECEVE, U1123, F-75010, Paris, France

    S. Gaudry

  4. Univ Paris Diderot, Sorbonne Paris Cité, IAME, UMRS 1137, F-75018, Paris, France

    D. Dreyfuss

  5. INSERM, IAME, U1137, F-75018, Paris, France

    D. Dreyfuss

Authors
  1. S. Gaudry
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  2. N. Zucman
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  3. D. Dreyfuss
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Corresponding author

Correspondence to S. Gaudry.

Additional information

Cet article correspond à la conférence faite par l’auteur au congrès de la SRLF 2015 dans la session : Épuration extrarénale.

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Gaudry, S., Zucman, N. & Dreyfuss, D. Critères de début et d’arrêt de l’épuration extrarénale en réanimation. Réanimation 24 (Suppl 2), 400–405 (2015). https://doi.org/10.1007/s13546-015-1028-8

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  • DOI: https://doi.org/10.1007/s13546-015-1028-8

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