Seminars in dialysis
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Seminars in dialysis · Mar 2011
ReviewWithholding and withdrawing renal support in acute kidney injury.
Management of critically ill patients with acute kidney injury (AKI) is mainly limited to supportive therapy, with dialysis as one of the main components. Whether or not to offer dialysis and when to withdraw dialysis is a one of the many choices physicians face in daily clinical practice. ⋯ An evidence-based guideline with nine specific recommendations for managing patients has been available however is infrequently employed to help clinical decision making. In this review, we discuss the important issues affecting decisions to withhold or withdraw dialysis in AKI patients and provide an approach for making these decisions for patient management.
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Seminars in dialysis · Mar 2011
ReviewBiomarker strategies to predict need for renal replacement therapy in acute kidney injury.
The early detection and diagnosis of acute kidney injury (AKI) with the standardization of novel kidney-injury-specific biomarkers is one of the highest research priorities in nephrology. Accordingly, the majority of studies of novel AKI biomarkers have focused on the early diagnosis of AKI using serum creatinine-based definitions as the gold standard. However, another potential application of kidney-injury-specific biomarkers is for guiding decisions on when to initiate renal replacement therapy (RRT). ⋯ However, published studies have many recognized limitations, which preclude our ability to adapt their findings into clinical practice today. While currently available data are not sufficient to conclude that biomarkers should be used routinely for clinical decision making for RRT initiation, additional data may in the future significantly modify the clinical variability for initiation of RRT, and potentially translate into improved outcomes and cost-effectiveness. Finally, we propose a potential approach to future biomarker strategies for RRT initiation, integrating these biomarkers with "traditional" clinical factors.
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Seminars in dialysis · Mar 2011
ReviewAssessing and delivering dialysis dose in acute kidney injury.
Assessing and delivering dialysis dose in acute kidney injury (AKI) has emerged as an important issue in the management of critically ill patients. There is ongoing debate on how dose of dialysis should be expressed and measured. ⋯ Recent evidence has shown that other markers may also be important to consider, as acid-base balance and fluid overload have emerged as important factors contributing to outcomes. In this review, we provide an evaluation of current approaches to prescribing and delivering dialysis dose in AKI, identify gaps in practice and propose an integrated approach to optimize dose delivery in dialysis with a goal to improve outcomes.
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Seminars in dialysis · Mar 2011
ReviewFinancial aspects of renal replacement therapy in acute kidney injury.
Acute kidney injury (AKI) is associated with high morbidity and mortality and consumes substantial health-care resources, particularly when renal replacement therapy is required. Randomized controlled trials (RCTs) have not identified the optimal mode of renal replacement for AKI in terms of clinically relevant endpoints such as patient survival or recovery of renal function. As for other complex health interventions, the costs and consequences of AKI treatment are relevant to health-care providers and decision makers aiming to maximize health outcomes despite fixed health resources. ⋯ On the other hand, while the incremental costs of providing CRRT are significant, they remain relatively small compared with the projected costs of providing chronic dialysis to survivors who do not recover renal function. Even small differences in the risk of chronic dialysis in survivors are likely to determine the economic attractiveness of the different types of renal replacement therapies. To clarify the true incremental cost-effectiveness of these therapies, future RCTs should collect data on long-term survival, the need for chronic dialysis, and detailed information on costs.
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Seminars in dialysis · Mar 2011
ReviewAdvances in pediatric renal replacement therapy for acute kidney injury.
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 comprised the most common pediatric acute renal failure etiologies; more recent data demonstrate that pediatric acute kidney injury (AKI) most often results from complications of other systemic diseases resulting from the advancements in congenital heart surgery, neonatal care, and bone marrow and solid organ transplantation. ⋯ In this article, we aim to review the pediatric specific causes for RRT provision, emphasizing the emerging practice patterns with respect to modality and timing of treatment. We will focus on the application of different RRT modalities and related outcome of children with AKI who receive RRT.