Continuous Renal-Replacement Therapy for Acute Kidney Injury

Tolwani, Ashita J.

doi:10.1056/nejmct1206045

Cited by 195 publications

(161 citation statements)

References 65 publications

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“…Despite advances in the understanding and management of AKI including introduction of RRT, mortality in ICU patients with AKI remains largely unimproved and unacceptably high. Moreover, mortality in ICU patients with AKI severe enough to require RRT has been reported to be as high as 80 % [2,3]. However, several issues regarding RRT remain to be solved in patients with AKI (Table 1).…”

Section: Introductionmentioning

confidence: 99%

Renal replacement therapy for acute kidney injury

et al. 2016

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The annual incidence of acute kidney injury (AKI) has been increasing as the population ages. Despite advances in critical care and dialysis technology, the mortality remains unacceptably high in patients with AKI during the past few decades. Renal replacement therapy (RRT) is performed to treat patients with severe AKI and multiple organ failures, as well as to remove fluid in patients with fluid overload including those with acute heart failure and lung edema in the intensive care unit (ICU). The mortality in patients with AKI requiring RRT is higher than 50 %. RRT strategies in patients with AKI depend on various conditions. However, there is little consensus on when to start and stop RRT, its optimal dose, and the choice of different RRT modalities (intermittent versus (vs.) continuous) in patients with AKI. Patients with AKI in the ICU are preferentially treated with continuous rather than intermittent RRT (IRRT), usually because of hemodynamic stability and steady of solute clearance. At present, the type and dose of RRT are dependent on the experience of the attending clinicians, including intensivists and nephrologists.

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Section: Introductionmentioning

confidence: 99%

Renal replacement therapy for acute kidney injury

et al. 2016

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“…However, given the overall equivalency of outcomes in dialysis-dependent patients with AKI treated with intermittent hemodialysis or with CRRT, the latter is used primarily in patients with hemodynamic instability requiring vasoactive support, severe volume overload, marginal BPs at risk for dysrhythmias with rapid volume removal during intermittent hemodialysis, severe catabolism or septic disorders (9)(10)(11). Hence, pharmacokinetic studies in hemodynamically unstable individuals with AKI undergoing CRRT may provide the most relevant data to inform clinical practice.…”

Section: Patient Populationsmentioning

confidence: 99%

Pharmacokinetic Assessment in Patients Receiving Continuous RRT

Nolin¹,

Aronoff²,

Fissell³

et al. 2015

Clinical Journal of the American Society of Nephrology

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The effect of AKI and modern continuous RRT (CRRT) methods on drug disposition (pharmacokinetics) and response has been poorly studied. Pharmaceutical manufacturers have little incentive to perform pharmacokinetic studies in patients undergoing CRRT because such studies are neither recommended in existing US Food and Drug Administration (FDA) guidance documents nor required for new drug approval. Action is urgently needed to address the knowledge deficit. The Kidney Health Initiative has assembled a work group composed of clinicians and scientists representing academia, the FDA, and the pharmaceutical and dialysis industries with expertise related to pharmacokinetics, AKI, and/or CRRT. The work group critically evaluated key considerations in the assessment of pharmacokinetics and drug dosing in CRRT, practical constraints related to conducting pharmacokinetic studies in critically ill patients, and the generalizability of observations made in the context of specific CRRT prescriptions and specific patient populations in order to identify efficient study designs capable of addressing the knowledge deficit without impeding drug development. Considerations for the standardized assessment of pharmacokinetics and development of corresponding drug dosing recommendations in critically ill patients with AKI receiving CRRT are proposed.

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“…Moreover, critically ill patients receive large amounts of fluid and in the presence of reduced renal function keeping the fluid balance is a challenge. Hence, CRRT treatment is appropriate for patients with hemodynamic instability, fluid overload, catabolism, or sepsis with acute kidney injury (AKI) [1].…”

Section: Continuous Renal Replacement Therapymentioning

confidence: 99%

“…Perfusion pressure generated by a peristaltic pump drives the ultrafiltration of plasma across a biosynthetic hemofiltration membrane. In this process, a high ultrafiltration rate is required to achieve convective clearance and hence replacement fluid must be added to the extracorporeal circuit to restore fluid volume and electrolytes [1].…”

Section: Continuous Renal Replacement Therapymentioning

confidence: 99%

Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy

Thajudeen¹,

Daheshpour²,

Bijin³

2016

Extracorporeal Membrane Oxygenation: Advances in Therapy

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Extracorporeal membrane oxygenation (ECMO) is a supportive therapy, which provides cardiopulmonary and end-organ support in critically ill patients when other measures fail. These patients receive large amounts of fluid for volume resuscitation, blood products and caloric intake, which results in fluid overload and which in turn is associated with impairment of oxygen transport and increased incidence of multiple organ failure especially heart, lungs and brain. It is common to see a decrease in urine output during ECMO that may be associated with acute renal failure. The acute renal failure is a manifestation of multiple organ system failure due to acute decompensated heart failure, sepsis, hemolysis, use of vasopressors/inotropes, nephrotoxic medications, and activation of complement system during ECMO support. It is associated with poor prognosis and higher mortality in ECMO patients. Continuous renal replacement therapy (CRRT) in patients on ECMO provides an efficient and potentially beneficial method of fluid overload and acute kidney injury management. In addition, recent data suggest that the use of CRRT may remove inflammatory cytokine released as a result of circulation of blood across synthetic surfaces during ECMO. The two most common methods to provide CRRT are through the use of an inline hemofilter or through a traditional CRRT device connected to the extracorporeal circuit. The primary objective of this chapter is to discuss current state and role of renal replacement therapy in patients on ECMO and address the controversies and challenges about its application.

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Continuous Renal-Replacement Therapy for Acute Kidney Injury

Abstract: This Journal feature begins with a case vignette highlighting a common clinical problem. Evidence supporting various strategies is then presented, followed by a review of formal guidelines, when they exist. The article ends with the author's clinical recommendations.

Cited by 195 publications

References 65 publications

Renal replacement therapy for acute kidney injury

Renal replacement therapy for acute kidney injury

Pharmacokinetic Assessment in Patients Receiving Continuous RRT

Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy

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