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Review
. 2020 May;115(Suppl 1):28-36.
doi: 10.1007/s00063-020-00658-3. Epub 2020 Feb 24.

Options in extracorporeal support of multiple organ failure

W Huber  1 , A P Ruiz de Garibay  2
Affiliations
Review

Options in extracorporeal support of multiple organ failure

W Huber et al. Med Klin Intensivmed Notfmed. 2020 May.

Abstract
in English, German

Multiorgan failure is among the most frequent reasons of death in critically ill patients. Based on extensive and long-term use of renal replacement therapy, extracorporeal organ support became available for other organ failures. Initially, most of these techniques (e.g. extracorporeal membrane oxygenation, extracorporeal CO2 removal [ECCO2R] and extracorporeal liver support) were used as stand-alone single organ support systems. Considering multiple interactions between native organs ("crosstalk"), combined or integrated extracorporeal organ support (ECOS) devices are intriguing. The concept of multiple organ support therapy (MOST) providing simultaneous and combined support for different failing organs was described more than 15 years ago by Ronco and Bellomo. This concept also implicates overcoming the "compartmentalized" approach provided by different single organ specialized professionals by a multidisciplinary and multiprofessional strategy. The idea of MOST is supported by the failure of several recent studies on single organ support including liver and lung support. Improvement of outcome by ECOS necessarily depends on optimized patient selection, integrated organ support and limitation of its side effects. This implicates challenges for engineers, industry and healthcare professionals. From a technical viewpoint, modular combination of pre-existing technologies such as renal replacement, albumin-dialysis, ECCO2R and potentially cytokine elimination can be considered as a first step. While this allows for stepwise and individual combination of standard organ support facilities, it carries the disadvantage of large extracorporeal blood volume and surfaces as well as additive costs. The more intriguing next step is an integrated platform providing the capacity of multiple organ support within one device. (This article is freely available.).

Das Multiorganversagen ist eine der häufigsten Todesursachen auf der Intensivstation. Die breite Anwendung der Nierenersatztherapie bei akutem und chronischem Nierenversagen ebnete den Weg für andere extrakorporale Organersatzverfahren. Diese wurden zunächst überwiegend als Einzelorganersatztherapien eingesetzt (extrakorporale Membranoxygenierung, extrakorporale CO2-Entfernung [ECCO2R] sowie extrakorporaler Leberersatz). Im Hinblick auf multiple Interaktionen zwischen den Organsystemen („crosstalk“) sind kombinierte bzw. integrierte Organersatzverfahren von großem Interesse. Das Konzept der „multiple organ support therapy“ (MOST) mit kombiniertem Organersatz wurde vor über 15 Jahren von Ronco und Bellomo erstbeschrieben. Dieses Konzept ersetzt den Ansatz der „Kompartimentalisierung“ mit Ersatz einzelner Organversagen im Rahmen der jeweiligen speziellen Verfahren durch eine multidisziplinäre, multiprofessionelle Vorgehensweise. Die Strategie der MOST gewann nach dem Scheitern mehrerer jüngster Studien zum Einzelorganersatz (v. a. Leber- bzw. Lungenersatz) zunehmend an Bedeutung. Der zukünftige Erfolg dieses Konzepts des integrierten Organersatzes hängt dabei auch von einer optimierten Patientenauswahl und einer Limitierung von Nebenwirkungen des Verfahrens ab. Dies bringt zwangsläufig Herausforderungen für Ingenieure, Industrie und Heilberufe mit sich. Technisch ist eine bloße Kombination von vorbestehenden Verfahren wie Nieren- oder Leberersatz, CO2-Entfernung und ggf. Zytokinelimination nur ein erster Schritt. Auch wenn dies eine schrittweise und individualisierte Kombination von vorhandenen Organunterstützungstherapien bedeutet, ergibt sich daraus der Nachteil eines hohen extrakorporalen Blutvolumens, großer künstlicher Oberflächen und additiver Kosten für die einzelnen Verfahren. Der notwendige nächste Schritt sind integrierte Verfahren, die einen Multiorganersatz in einem Gerät ermöglichen.

Keywords: Albumin dialysis; Extracorporeal CO2 removal; Extracorporeal organ support; Plasma separation; Renal replacement therapy.

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Conflict of interest statement

W. Huber is member of the Medical Advisory Board of Pulsion Medical systems SE (Getinge Group). W. Huber received speaker’s fees and travel reimbursement by ADVITOS GmbH. W. Huber is principal investigator of a clinical ECMO study supported by NovaLung/Xenios (Fresenius Medical Care). W. Huber is principal investigator of an animal study on ECMO and hemodynamics supported by Maquet GmbH (Getinge Group). A.P. Ruiz de Garibay is in an employment relationship with ADVITOS GmbH.

Figures

Fig. 1
Fig. 1
Development of extracorporeal organ support (ECOS). ARDS Acute Respiratory Distress Syndrome, CE Conformité Européenne
See this image and copyright information in PMC

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