Contributions to nephrology
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Review Comparative Study
Continuous renal replacement in critical illness.
Acute renal failure in the intensive care unit is usually part of the multiple organ dysfunction syndrome, and the complexity of illness in patients with this complication has risen in recent years. Continuous renal replacement therapy (CRRT) was introduced in the late 1970s and early 1980s to compensate for the inadequacies of conventional intermittent hemodialysis (IHD) in the treatment of these patients. IHD was considered aggressive and unphysiological, often resulting in hemodynamic intolerance and limited efficiency. ⋯ However, these studies are generally underpowered and have certain aspects which may influence the interpretation of their results. In addition, the development of hybrid techniques, such as slow extended daily dialysis, makes this a dynamic area of study where the terms of comparison are constantly changing. This article reviews recent trials comparing CRRT and IHD, and discusses their results and limitations.
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Acute kidney injury (AKI) is a common and serious postoperative complication following exposure to cardiopulmonary bypass (CPB). Several mechanisms have been proposed by which the kidney can be damaged and interventional studies addressing known targets of renal injury have been undertaken in an attempt to prevent or attenuate CPB-associated AKI. However, no definitive strategy appears to protect a broad heterogeneous population of cardiac surgery patients from CPB-associated AKI. ⋯ Sodium bicarbonate is safe, simple to administer and inexpensive. If part of AKI after CPB is truly secondary to hemoglobin-induced pigment nephropathy, prophylactic sodium bicarbonate infusion might help attenuate it. A trial of such treatment might be a reasonable future investigation in higher risk patients receiving CPB.
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The practice of renal replacement therapy (RRT) has reached an optimal standard of care worldwide. Nevertheless, some aspects of acute renal failure treatment and support still present wide variability between different centers. This is especially true for the mode and dose of RRT. This review describes the epidemiology of dialysis prescription and delivery around the world based on recent observational studies and international surveys. ⋯ A trend to continuous therapies and increased RRT dosage over the last 10 years is shown by the surveys presented, even if scientific evidence is now very necessary as far as definitive RRT indications and prescriptions are concerned.
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Sustained low-efficiency dialysis (SLED) is an increasingly popular form of renal replacement therapy for patients with renal failure in the intensive care unit. Advantages of SLED are efficient clearance of small solutes, good hemodynamic tolerability, flexible treatment schedules, and reduced costs. Studies comparing outcomes of SLED with those of other dialysis modalities are being performed.
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Traditionally the epidemiology of acute renal failure was assessed in patients requiring renal replacement therapy. Recent data emphasized the importance of less severe impairment of kidney function, hence the terminology acute kidney injury (AKI) was introduced. ⋯ Small changes in kidney function have an impact on outcomes and this knowledge has led to the introduction of the terminology AKI, encompassing both discrete and severe impairment of kidney function. The RIFLE classification describes the whole range of AKI and has been validated in multiple cohorts. As a consequence of increasing comorbidity, the incidence of AKI is increasing. The incidence of acute renal failure requiring renal replacement therapy even compares to that of acute lung injury, and up to two thirds of general ICU patients meet RIFLE criteria for AKI.