CHDFは意味があるか? : 急性膵炎の診療ガイドラインにおけるCHDFの位置づけ  [in Japanese] Is Continuous Hemodiafiltration (CHDF) Always Useful in Treating Severe Acute Pancreatitis?  [in Japanese]

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全国集計では重症急性膵炎(以下,SAP)に対する血液浄化法(以下,BP)として CHDFが最も多く行われているが,その救命率は芳しくない。しかし,この報告では施行された BPの目的,開始のタイミングや施行方法等,いずれも一定ではなく,その効果の実態を導きだせるものではない。SAPに対する CHDFの効果を検証するにはその適応が合併した急性腎不全に対するものなのか(renal indication)膵炎の病態を増悪しうる病因物質除去効果を期待したものなのか(non-renal indication)を考慮して検討する必要がある。また,使用した血液浄化器の素材も病因物質除去効果に影響するかもしれない。CHDFの臓器不全予防効果に関してはその有効性を示唆する研究が報告されているが,信頼しうるデータに乏しく,その推奨度はレベルの低いエビデンスに基に決めざるをえない。(non-renal indication:推奨度C1)。また,急性腎不全に対するBPの開始タイミングは発症早期の方が有効であるという最近の知見より十分な輸液にもかかわらず,循環動態が不安定で利尿の得られないSAPでは積極的にCHDFを施行すべきである(renal indication:推奨度B)。

A nationwide survey demonstrated that continuous hemodiafi ltration (CHDF) is the blood purifi cation (BP) therapy most frequently performed in severe acute pancreatitis (SAP) ,though it results in poor survival. It also showed that the indications for and modality of BP as well as the timing of its initiation varied. Accordingly, the actual therapeutic effects of CHDF in SAP cannot be evaluated from these fi ndings. To determine the real clinical effi cacy of CHDF, whether it is performed to improve complicating acute renal failure (renal indication) or to remove causative humoral mediators exacerbating clinical pancreatitis (non-renal indication) should be considered. Also, the effects of CHDF may depend on the material of the membrane fi lter matrix in the hemofi lter. Although the effectiveness of CHDF in preventing organ failure has been suggested in several studies, the reliability of the data was limited, and recommendations for use of CHDF for this purpose (non-renal indication;Recommendation C1) had to be determined based on a lower level of evidence. However, aggressive CHDF is recommended for SAP with unstable hemodynamics and unsuccessful diuresis despite suffi cient volume infusion (renal indication;Recommendation B) ,as supported by recent fi ndings that earlier initiation of BP is more effi cacious in treating acute renal failure.


  • Progress in Acute Abdominal Medicine  

    Progress in Acute Abdominal Medicine 28(4), 581-585, 2008-05-31 

    Japanese Society for Abdominal Emergency Medicine

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