High-Volume Hemofiltration in the Intensive Care Unit

Abstract Systemic inflammatory response syndrome (SIRS), sepsis, septic shock, and acute pancreatitis are known to be the leading causes of acute renal failure in the intensive care unit (ICU), and they create an immunologic disturbance with a cytokine storm. In fact, it has been claimed that a large and unspecific cytokine reduction in the blood compartment in theory could reduce mortality more than by a simple concentration on one specific element. Animal models have shown benefits in terms of survival when “early” and “strong” hemofiltration doses were applied in septic animals. Some human studies in the early 20th century concentrated on hemodynamic response, and cytokine removal showed interesting hemodynamic improvement in patients with sepsis treated by high-volume hemofiltration (HVHF) and a possible survival improvement in comparison with the expected one. However, the recent randomized controlled trials failed to prove any benefit to HVHF, whether it be used in patients with sepsis or those who have had cardiac surgery. The possible beneficial effect in terms of cytokine removal or inflammatory “control” has been balanced by the antibiotic underdosage and lack of essential elements (e.g., amino acids, trace elements). However, even with a cascade hemofiltration technique that was able to remove only middle-size molecules and keep small ones (as antibiotics or trace elements) in the patient, the last trial was negative. In conclusion, HVHF or derived techniques are not recommended to treat inflammatory or septic patients outside specific research. The standard dosage of 25 mL/kg/hr should be applied for every ICU patient.