American journal of kidney diseases : the official journal of the National Kidney Foundation
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Comparative Study
Comparing continuous hemofiltration with hemodialysis in patients with severe acute renal failure.
Continuous venovenous hemofiltration (CVVH) or CVVH with additional diffusive dialysis (CVVH-D) has theoretical advantages in treating severe acute renal failure (ARF), but no prospective clinical trials or restrospective comparison studies have clearly shown its superiority over intermittent hemodialysis (HD). To evaluate this question, all 349 adult patients with ARF receiving renal replacement therapy (RRT) at our medical center during 1995 and 1996 were analyzed using multivariate Cox proportional hazards methods. Initial univariate analysis showed the odds of death when receiving initial CVVH to be more than twice those when receiving initial HD (risk for death, 2.03; P < 0.01). ⋯ Comorbid indicators significantly associated with death or failure to recover renal function included: older age; medical rather than surgical diagnosis; preexisting infection or trauma and liver disease as primary diagnoses; and abnormal bilirubin level or vital signs at initiation of RRT. These results show that the high crude mortality rate of patients undergoing CVVH was related to severity of illness and not the treatment choice itself. With the addition of more inclusive comorbidity data and a broader spectrum of interim outcomes, this type of analysis is a practical alternative to what would almost assuredly be a cumbersome and costly prospective, controlled trial comparing traditional HD with CVVH.
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The cause of anemia in chronic renal failure is multifactorial. Decreased erythropoietin (EPO) production is the main pathogenetic factor, but iron deficiency is the primary cause of unresponsiveness to EPO therapy. The diagnosis of iron deficiency in patients with chronic renal failure is difficult. ⋯ The remaining parameters showed areas under the ROC curve less than 0.65. Although serum transferrin receptor and erythrocyte ferritin may be acceptable markers for iron deficiency in stable chronic renal failure patients, serum ferritin level continues to be the most reliable diagnostic parameter. Transferrin saturation index is not a reliable parameter for the diagnosis of iron deficiency in stable patients not treated with rHuEPO.
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Clearances of several solutes (urea, creatinine, phosphate, urates, beta(2)-microglobulin [beta(2)-M]) were measured during venovenous continuous renal replacement therapy (CRRT) at various ultrafiltration (Q(UF); 0 to 2 L/h) and dialysate flow rates (Q(D); 0 to 2.5 L/h). Preset Multiflow-60 and Multiflow-100 hollow-fiber dialysers (M-60 and M-100; Hospal-Gambro, St-Leonard, Canada) were compared (five patients for each type). First, we evaluated the impact of predilution on convective clearances: a progressive decrease in patient clearances, similar for both filters, was observed, reaching a maximum of 15%, 18%, and 19% for urea, urates, and creatinine, respectively, with predilution at a Q(UF) of 2 L/h. ⋯ However, for beta(2)-M, the addition of diffusion (Q(D), 0.5 to 2.5 L/h) did not result in any significant increase in total clearances over convective clearances for M-60 and M-100. This observation suggests that the diffusive clearances for beta(2)-M observed with M-60 and M-100 at a Q(UF) of 0 L/h and at various Q(D) probably occurs by convective fluxes across the membrane. These results demonstrate that convection is more efficient than diffusion in removing mixed-molecular-weight solutes during CRRT.