Artificial organs
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Increasing attention is being paid to quantifying the dose of dialysis prescribed and delivered to critically ill patients with acute renal failure (ARF). Recent trials in both the intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) realms have suggested that a direct relationship between dose and survival exists for both of these therapies. ⋯ Subsequently, the factors influencing dose prescription and delivery are discussed, with the focus on continuous venovenous hemofiltration (CVVH). Specifically, differences between postdilution and predilution CVVH will be highlighted, and the importance of blood flow rate in dose delivery for these therapies will be discussed.
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Severe sepsis and septic shock are the primary causes of multiple organ dysfunction syndrome (MODS), which is the most frequent cause of death in intensive care unit patients. Many water-soluble mediators with pro- and anti-inflammatory action such as TNF, IL-6, IL-8, and IL-10 play a strategic role in septic syndrome. ⋯ CRRT is a continuously acting therapy, which removes in a nonselective way pro- and anti-inflammatory mediators; "the peak concentration hypothesis" is the concept of cutting peaks of soluble mediators through continuous hemofiltration. Furthermore, there is evidence of increased efficacy of high-volume hemofiltration compared to conventional CVVH, and other blood purification techniques that utilize large-pore membranes or sorbent plasmafiltration are conceptually interesting.
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Individuals engaged in the fields of artificial kidney and artificial heart have often mistakenly stated that "the era of artificial organs is over; regenerative medicine is the future." Contrarily, we do not believe artificial organs and regenerative medicine are different medical technologies. As a matter of fact, artificial organs developed during the last 50 years have been used as a bridge to regeneration. The only difference between regenerative medicine and artificial organs is that artificial organs for the bridge to regeneration promote tissue regeneration in situ, instead of outside the body (for example, vascular prostheses, neuroprostheses, bladder substitutes, skin prostheses, bone prostheses, cartilage prostheses, ligament prostheses, etc.). ⋯ It does not matter whether these tissues are cultivated inside or outside the patient's body. Thus, we strongly believe in the need for joint development programs between artificial organ technologies and regenerative medicine technologies. In particular, the importance of using both man-made substitute organ technologies and natural tissue-derived substitute organ technologies is stressed for improved medical care in the future.
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The disease spectrum leading to pediatric renal replacement therapy (RRT) provision has broadened over the last decade. In the 1980s, intrinsic renal disease and burns constituted the most common pediatric acute renal failure etiologies. ⋯ Currently, multicenter prospective outcome studies for critically ill children with ARF are sorely lacking. The aims of this article are to review the pediatric specific causes necessitating renal replacement therapy provision, with an emphasis on emerging practice patterns with respect to modality and the timing of treatment, and to focus upon the application of the different renal replacement therapy modalities and assessment of the outcome of children with ARF who receive renal replacement therapy.
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Comparative Study
Kinetic comparison of different acute dialysis therapies.
Recent clinical data indicate both ultrafiltration rate (Qf) and timing of treatment initiation in continuous renal replacement therapy (CRRT) and therapy frequency in intermittent hemodialysis (HD) influence survival in critically ill patients with acute renal failure (ARF). In this study, kinetic modeling is used to compare effective dose delivery by three acute dialysis therapies: continuous venovenous hemofiltration (CVVH), daily HD, and sustained low-efficiency dialysis (SLED). A modified equivalent renal clearance (EKR) approach to account for the initial unsteady-state stage during dialysis is employed. ⋯ The superior middle and large solute removal for CVVH is due to the powerful combination of convection and continuous operation. In CVVH, a decrease in the initial BUN from 150 to 50 mg/dL is predicted to decrease TAC and, therefore, increase EKR by approximately 35%. After clinical validation, the quantification method presented in this article could be a useful tool to assist in the dialytic management of critically ill ARF patients.