Continuous Renal-Replacement Therapy for Acute Kidney Injury Reply
ABSTRACT Acute limb ischemia due to a perioperative type B (distal) thoracic aortic dissection develops in a 90-kg, 20-year-old man with Marfan's syndrome who is admitted to the hospital for elective aortic-valve replacement. On postoperative day 1, he undergoes endovascular repair of the thoracic aorta. On postoperative day 4, his urine output decreases to 420 ml over a 24-hour period. He requires mechanical ventilation with a fraction of inspired oxygen (FiO(2)) of 0.70; his mean arterial pressure is 74 mm Hg with vasopressor support. He has had a positive fluid balance of 9.8 liters since admission. The serum creatinine level has increased from a baseline of 0.6 mg per deciliter (53.0 mu mol per liter) to 4.4 mg per deciliter (389.0 mu mol per liter). The bicarbonate level is 19 mmol per liter despite bicarbonate infusion, and the potassium level is 6.1 mmol per liter. The creatine kinase level has increased to 129,040 U per liter. An intensive care specialist evaluates the patient and recommends initiation of continuous renal-replacement therapy.
- SourceAvailable from: Darryl Abrams01/2013; 15(12):1050-1055. DOI:10.1001/virtualmentor.2013.15.12.stas2-1312
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ABSTRACT: Familiarity with the initiation, dosing, adjustment, and termination of continuous renal replacement therapy (CRRT) is a core skill for contemporary intensivists. Guidelines for how to administer CRRT in the intensive care unit are not well documented. The purpose of this review is to discuss the modalities, terminology, and components of CRRT, with an emphasis on the practical aspects of dosing, adjustments, and termination. Management of electrolyte and acid-base derangements commonly encountered with acute renal failure is emphasized. Knowledge regarding the practical aspects of managing CRRT in the intensive care unit is a prerequisite for achieving desired physiological end points.Journal of critical care 07/2013; 28(6). DOI:10.1016/j.jcrc.2013.05.018
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ABSTRACT: A significant proportion of patients treated for acute decompensated heart failure (ADHF) suffer from worsening renal function, which is often associated with medical therapy resistance and poor outcome. In this setting, haemofiltration has been used for more than 30 years, despite inconclusive evidence for its advantages. In the last decade, a major technological advances have made available a new technique, ultrafiltration, which works at lower blood flow rates and requires only a venous access. As in a first proof-of-concept study (EUPHORIA), ultrafiltration proved to be efficacious in fluid removal in ADHF patients; this treatment was further investigated in randomized controlled trials. The RAPID-CHF trial demonstrated that ultrafiltration was more effective than medical therapy in fluid removal, even though it did not provide a greater weight loss. The UNLOAD trial thereafter showed a greater weight loss with ultrafiltration compared with diuretic therapy at 48 h after admission and a lower readmission rate at 90 days. Based on these results, the AHA/ACC and ESC guidelines consider ultrafiltration as a reasonable approach in ADHF patients with unresolved congestion notwithstanding optimal medical therapy and/or hyponatremia. However, the recently published CARRESS-HF trial would appear to challenge these recommendations as it failed to demonstrate an advantage of ultrafiltration compared with medical therapy, based on the finding of subtle clinically irrelevant changes in renal function between treatments. This review focused on the current evidence supporting the use of ultrafiltration and on a critical appraisal of the recently published CARRESS-HF trial.Nephrology Dialysis Transplantation 09/2013; DOI:10.1093/ndt/gft371