Hemofiltration and Hybrid Therapies in 2010

  • P. M. Honoré
  • O. Joannes-Boyau
  • T. Rose
Conference paper


Despite major recent therapeutic improvements, septic shock remains a leading cause of mortality in intensive care patients [1]. In addition, it is important to realize that the mortality rate of patients with septic acute kidney injury (AKI) is much higher than that of patients with non-septic AKI [2]. For more than a decade, it has been suggested that reducing blood cytokine levels in such patients could, at least theoretically, lead to reduced mortality [3, 4]; however, in view of the complexity of the pharmacodynamics and pharmacokinetics of cytokines, this concept is not so simple to apply. Indeed, recent studies have attempted to demonstrate that high volume hemofiltration (HVHF) with enhanced adsorption can modulate and ameliorate sepsis-induced hemodynamic instability [5]. This recently published paper [5] suggested that membranes with enhanced adsorption are the key and that increased extraction from the central circulation is sufficient to obtain a beneficial clinical effect. It seems at least theoretically reasonable that effectively removing mediators from the tissue where they are harmful, and transporting them to the central circulation must be effective. Therefore, HVHF and enhanced adsorption should work synergistically in this model. In order to consolidate this hypothesis, it seems fruitful to discuss the three separate theories that have been put forward in recent years as possible explanations for the clinical findings observed in septic patients who underwent a number of different blood purification techniques. The HVHF and hybrid techniques that are currently available to the clinician are diverse and deserve a brief description.


Septic Shock Renal Replacement Therapy Acute Kidney Injury Septic Patient Blood Compartment 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


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  1. 1.
    Vincent JL, Atalan HK (2008) Epidemiology of severe sepsis in the intensive care unit. Br J Hosp Med 69: 442–443Google Scholar
  2. 2.
    Parmar A, Langenberg C, Wan L, May CN, Bellomo R, Bagshaw SM (2010) Epidemiology of septic acute kidney injury. Curr Drug Targets (in press)Google Scholar
  3. 3.
    Casey LC, Balk RA, Bone RC (1993) Plasma cytokine and endotoxin levels correlate with survival in patients with the sepsis syndrome. Ann Intern 119: 771–778Google Scholar
  4. 4.
    Damas P, Canivet JL, de Groote D, et al (1997) Sepsis and serum cytokine concentrations. Crit Care Med 25: 405–412CrossRefPubMedGoogle Scholar
  5. 5.
    Rimmele T, Assadi A, Cattenoz M, et al (2009) High-volume haemofiltration with a new haemofiltration membrane getting enhanced adsorption properties in septic pigs. Nephrol Dial Transplant 24: 421–427CrossRefPubMedGoogle Scholar
  6. 6.
    Schrier RW, Wang W (2004) Acute renal failure and sepsis. N Engl J Med 351: 159–169CrossRefPubMedGoogle Scholar
  7. 7.
    Wan L, Bagshaw SM, Langenberg C, Saotome T, May C, Bellomo R (2008) Pathophysiology of septic acute kidney injury: what do we really know? Crit Care Med 36: 198–203CrossRefGoogle Scholar
  8. 8.
    Hotchkiss RS, Swanson PE, Freeman BD, et al (1999) Apoptotic cell death in patients with sepsis, shock and multiple organ dysfunction. Crit Care Med 27: 1230–1251CrossRefPubMedGoogle Scholar
  9. 9.
    Bellomo R, Wan L, Langenberg C, May C (2008) Septic acute kidney injury: new concepts. Nephron Exp Nephrol 4: 95–100CrossRefGoogle Scholar
  10. 10.
    Abraham E, Singer M (2007) Mechanisms of sepsis-induced organ dysfunction. Crit Care Med 35: 2408–2416CrossRefPubMedGoogle Scholar
  11. 11.
    Ronco C, Tetta C, Mariano F, Wratten ML, Bonello M, Bellomo R (2003) Interpreting the mechanism of continuous renal replacement therapy in sepsis. The peak concentration hypothesis. Artif Organs 27: 792–801CrossRefPubMedGoogle Scholar
  12. 12.
    Ronco C, Bellomo R (2002) Acute renal failure and multiple organ dysfunction in the ICU: from renal replacement therapy (RRT) to multiple organ support therapy (MOST). Int J Artif Organs 25: 733–747PubMedGoogle Scholar
  13. 13.
    Ronco C, Ricci Z, Bellomo R (2002), Importance of increased ultrafiltration volume and impact on mortality: sepsis and cytokine story and the role for CVVH. EDTRA ERCA J 2: 13–18Google Scholar
  14. 14.
    Honoré PM, Joannes-Boyau O (2004) High volume hemofiltration (HVHF) in sepsis: a comprehensive review of rationale, clinical applicability, potential indications and recommendations for future research. Int J Artif Organs 27: 1077–1082PubMedGoogle Scholar
  15. 15.
    Honore PM, Matson JR (2004) Extracorporeal removal for sepsis: acting at the tissue level — the beginning of a new era for this treatment modality in septic shock. Crit Care Med 32: 896–897CrossRefPubMedGoogle Scholar
  16. 16.
    Honoré PM, Jamez J, Wauthier M, Dugernier T (1998) Prospective evaluation of short-time high volume isovolemic hemofiltration on the haemodynamic course and outcome of patients with refractory septic shock. Crit Care Nephrol 90: 87–99Google Scholar
  17. 17.
    Honoré PM, Zydney AL, Matson JR (2003) High volume and high permeability haemofiltration in sepsis. The evidences and the key issues. Care Crit III 3: 69–76Google Scholar
  18. 18.
    Klouche K, Cavadore P, Portales P, Clot J, Canaud B, Beraud JJ (2002) Continuous venovenous hemofiltration improves hemodynamic in septic shock with acute renal failure without modifying TNF-α and IL-6 plasma concentrations. J Nephrol 15: 150–157PubMedGoogle Scholar
  19. 19.
    Di Carlo JV, Alexander SR (2005) Hemofiltration for cytokine-driven illness: the mediator delivery hypothesis. Int J Artif Organs 28: 777–786PubMedGoogle Scholar
  20. 20.
    Olszewski WL (2003) The lymphatic system in body homeostasis: physiological conditions. Lymph Fat Res BioI 1: 11–21CrossRefGoogle Scholar
  21. 21.
    Onarherim H, Missavage E, Gunther RA, Kramer GC, Reed RK, Laurent TC (1991) Marked increase of plasma hyaluronan after major thermal injury and infusion therapy. J Surg Res 50: 259–265CrossRefGoogle Scholar
  22. 22.
    Wasserman K, Mayerson HS (1952) Dynamics of lymph and plasma protein and exchange. Cardiologia 21: 296–307CrossRefPubMedGoogle Scholar
  23. 23.
    Honore PM, joannes-Boyau O, Collin V, Boer W, Gressens B, Janvier G (2008) Practical daily management of extra-renal continuous removal. Reanimation 17: 472–478CrossRefGoogle Scholar
  24. 24.
    Honoré PM, Matson JR (2002) Hemoflitration.adsorption, sieving and the challenge of sepsis therapy design. Crit Care 6: 394–396CrossRefPubMedGoogle Scholar
  25. 25.
    Sykora R, Chvojka J, Krouzecky A, et al (2009) High versus standard-volume haemofiltration in hyperdynamic porcine peritonitis: effects beyond haemodynamics? Intensive Care Med 35: 371–380CrossRefPubMedGoogle Scholar
  26. 26.
    Cruz DN, Antonelli M, Fumagalli R et al (2009) Early use of polymyxin b hemoperfusion in abdominal septic shock: the EUPHAS Randomized Controlled Trial. JAMA 301: 2445–2452CrossRefPubMedGoogle Scholar
  27. 27.
    Honore PM, Joannes-Boyau O, Gressens B (2007) Blood and plasma treatments: High-volume hemofiltration — A global view. Contrib Nephrol 156: 371–386CrossRefPubMedGoogle Scholar
  28. 28.
    Yekebas EF, Eisenberger CF, Ohnnesorge H, et al (2001) Attenuation of sepsis-immunoparalysis with continuous veno venous haemofiltration in experimental porcine pancreatitis. Crit Care Med 29: 1423–1430CrossRefPubMedGoogle Scholar
  29. 29.
    Bone RC (1996) Sir Isaac Newton. Sepsis, SIRS and CARS. Crit Care Med 24: 1125–1128CrossRefPubMedGoogle Scholar
  30. 30.
    Kellum JA, Song M, Venkataraman R (2004) Hemoadsorption removes tumor necrosis factor, interleukin-o, and interleukin-IO, reduces nuclear factor-kappaB DNA binding, and improves short-term survival in lethal endotoxemia. Crit Care Med 32: 801–805CrossRefPubMedGoogle Scholar
  31. 31.
    Li CM, Chen JH, Zhang P, et al (2007) Continuous veno-venous haemofiltration attenuates myocardial mitochondrial respiratory chain complexes activity in porcine septic shock. Anaesth Intensive Care 35: 911–919PubMedGoogle Scholar
  32. 32.
    Matson J R, Zydney AR, Honore PM (2004) Blood filtration: New opportunities and the implications on system biology. Crit Care Resuc 6: 209–218Google Scholar
  33. 33.
    Ioannes-Boyau O, Honoré PM, Boer W, Collin V (2009) Are the synergistic effects of highvolume haemofiltration and enhanced adsorption the missing key in sepsis modulation? Nephrol Dial Transplant 24: 354–357CrossRefGoogle Scholar
  34. 34.
    Devarajan P (2005) Cellular and molecular derangements in acute tubular necrosis. Curr Opin Pediatr 17: 193–199CrossRefPubMedGoogle Scholar
  35. 35.
    Rana A, Sathyanarayana P, Lieberthal W (2001) Role of apoptosis of renal tubular cells in acute renal failure:therapeutic implications. Apoptosis 6: 83–102CrossRefPubMedGoogle Scholar
  36. 36.
    Boneggio R, Lieberthal W (2002) Role of apoptosis in the pathogenesis of acute renal failure. Curr Opin Nephrol Hypertens 11: 301–308CrossRefGoogle Scholar
  37. 37.
    Homsi E, Janino P, de Faria JB (2006) Role of caspases on cell death, inflammation, and cell cycle in glycerol-induced acute renal failure. Kidney Int 69: 1385–1392PubMedGoogle Scholar
  38. 38.
    Guo R, Wang Y, Minto AW, Quigg RJ, Cunningham PN (2004) Acute renal failure in endotoxemia is dependant on caspase activation. J Am Soc Nephrol 15: 3093–3102CrossRefPubMedGoogle Scholar
  39. 39.
    Mariano F, Cantaluppi V, Stella M, et al (2008) Circulating plasma factors induce tubular and glomerular alterations in septic burns patients. Crit Care 12:R42CrossRefPubMedGoogle Scholar
  40. 40.
    Honore PM, Joannes-Boyau O, Boer W, Collin V (2009) High-volume hemofiltration in sepsis and SIRS: current concepts and future prospects. Blood Purif 28: 1–11CrossRefPubMedGoogle Scholar
  41. 41.
    Palevsky PM, Zhang JH, O'Connor TZ, et al (2008) Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med 359: 7–20CrossRefPubMedGoogle Scholar
  42. 42.
    Ronco C, Honore PM (2008), Renal support in critically ill patients with acute kidney injury. N Engl J Med 359: 1959–1962CrossRefPubMedGoogle Scholar
  43. 43.
    Ronco C, Cruz D, Oudemans-van-Straaten HM, et al (2008) Dialysis dose in acute kidney injury: no time for therapeutic nihilism-a critical appraisal of the Acute Renal Failure Trial Network study. Crit Care 12: 308CrossRefPubMedGoogle Scholar
  44. 44.
    Bell M, SWING, Granath F, Schon S, Ekbom A, Martling CR (2007) Continuous renal replacement therapy is associated with less chronic renal failure than intermittent haemodialysis after acute renal failure. Intensive Care Med 33: 773–780CrossRefPubMedGoogle Scholar
  45. 45.
    Ridel C, Balde MC, Rondeau E, Vinsonneau C (2009) Dose of dialysis in intensive care unit. Reanimation 18: 385–396CrossRefGoogle Scholar
  46. 46.
    Bellomo R, Cass A, Cole L, et al (2009) Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med 361: 1627–1628CrossRefPubMedGoogle Scholar
  47. 47.
    Ioannes-Boyau O, Honore PM Hemofiltration Study: IVOIRE Study. Available at: Accessed Dec 2009Google Scholar
  48. 48.
    Ronco C, Bellomo R, Homel P, et al (2000) Effects of different doses in continuous venovenous haemofiltration. Lancet 356: 26–30CrossRefPubMedGoogle Scholar
  49. 49.
    Vesconi S, Cruz DN, Fumagalli R, et al (2009) Delivered dose of renal replacement therapy and mortality in critically ill patients with acute kidney injury. Crit Care 13: R57CrossRefPubMedGoogle Scholar
  50. 50.
    Schiffl H, Lang SM, Fisher R (2002) Daily hemodialysis and the outcome of acute renal failure. N Engl J Med 346: 305–310CrossRefPubMedGoogle Scholar

Copyright information

© Springer Science + Business Media Inc. 2010

Authors and Affiliations

  • P. M. Honoré
    • 1
  • O. Joannes-Boyau
    • 2
  • T. Rose
    • 1
  1. 1.ICU High and Medium Care Burn CenterQueen Astrid Military HospitalBrusselsBelgium
  2. 2.Department of Intensive CareHaut Leveque University Hospital of BordeauxPessacFrance

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