Adequacy of Dialysis in the Acute Renal Failure of the Critically ILL: The Case for Continuous Therapies

Bellomo, Rinaldo; Ronco, Claudio

doi:10.1177/039139889601900217

Cited by 23 publications

(2 citation statements)

References 136 publications

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“…ARF in the critically ill patient is frequently part of multiple organ failure (MOF) and sepsis, and patients, independent from other comorbidities and despite technical improvements in RRT delivery, are still dying of ARF (50): it is evident that absence of kidney function accounts for some specific and independent risk factor for poor prognosis of unknown magnitude. Hence, beyond "adequate" RRT dose for ARF, there may be a role for an "adequate" RRT dose for ARF with sepsis, intended as a hypothetical therapy that would closely mimic the features of the native kidney in this setting and perhaps enhance them (51). It is logical to hypothesize that the blood purification dose needed in patients with uncomplicated ARF would be very different from that needed in patients with ARF in the setting of septic MOF.…”

Section: Is There Adequacy Beyond Adequacy?mentioning

confidence: 99%

Dose of Dialysis in Acute Renal Failure

Ricci

Bellomo

Ronco

2006

Clinical Journal of the American Society of Nephrology

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O ne to 25% of critically ill patients who are admitted to intensive care unit (ICU) develop acute renal failure (ARF), depending on the definition used (1). ARF has a significant impact on morbidity and represents an independent risk factor for mortality. The mortality rate for severe ARF exceeded 50% over the past three decades (2-6). The wide range of incidence in the literature depends on the lack of a reliable definition of the syndrome. On the basis of the most recent RIFLE classification (an acronym indicating Risk of renal dysfunction, Injury to the kidney, Failure of kidney function, Loss of kidney function, and ESRD) (7), ARF can be stratified for severity, and different outcomes depend on the degree of severity as assessed by the extent of GFR loss. Current management depends on the level of severity and includes optimization of hemodynamics and fluid status, avoidance of further renal insults, optimization of nutrition, and, when appropriate, the application of renal replacement therapy (RRT).Indications for RRT generally are clear for patients with the most severe of conditions (e.g., anuria with severe hyperkalemia in the setting of septic shock), whereas they can be a matter of controversy and require individualized assessment in less severe situations (e.g., polyuric ARF in a patient who has previous chronic renal dysfunction and is otherwise well 2 d after cardiac surgery). Optimal strategies to improve patient outcome in ARF may include optimization of delivered . This review focuses on RRT dose and its measurement and prescription in the ICU and on the current evidence concerning the relationship between RRT dose and outcome. What Is RRT Dose, and How Is It Measured?The conventional view of RRT dose is that it is a measure of the quantity of blood purification achieved by means of extracorporeal techniques. As this broad concept is too difficult to measure and quantify, the operative view of RRT dose is that it is a measure of the quantity of a representative marker solute that is removed from a patient. This marker solute is taken to be reasonably representative of similar solutes, which require removal for blood purification to be considered adequate. This premise has several major flaws: the marker solute cannot and does not represent all of the solutes that accumulate in renal failure. Its kinetics and volume of distribution are also different from such solutes. Finally, its removal during RRT is not representative of the removal of other solutes. This is true for both end-stage renal failure and acute renal failure. However, a significant body of data in the end-stage renal failure literature (16 -21) suggests that, despite all of the above major limitations, single solute marker assessment of dose of dialysis seems to have a clinically meaningful relationship with patient outcome and, therefore, clinical utility. Nevertheless, the HEMO study, examining the effect of intermittent hemodialysis (IHD) doses, failed to confirm the intuition that "more dialysis (than recommended by current gui...

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Section: Is There Adequacy Beyond Adequacy?mentioning

confidence: 99%

Dose of Dialysis in Acute Renal Failure

Ricci

Bellomo

Ronco

2006

Clinical Journal of the American Society of Nephrology

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show abstract

“…Beyond such observations, a solutebased approach to the concept of dose seems too 'monodimensional', although operatively relatively simple and, by analogy with end stage renal failure, potentially linked to outcome. In critically ill patients with acute renal failure, other dimensions of adequacy of RRT or RRT dose remain unexplored but likely to also be important [16][17]. Future studies should focus on other aspects of dose (volume control, acid-base control, tonicity control and so on) and assess their potential link with outcome.…”

Section: Resultsmentioning

confidence: 99%