Hemodiafiltración intermitente en línea como terapia de reemplazo renal en paciente crítico: Experiencia en un centro de diálisis de agudo

Abstract

Experience with inline intermittent hemodiafiltration as renal replacement therapy in critically ill patients Background: In critical patients with acute renal failure, intermittent diffusive renal replacement techniques cause hemodynamic problems due to their high depurative efficiency. This situation is avoided using continuous low efficiency therapies, which are expensive, prevent patient mobilization and add hemorrhagic risk due to systemic anticoagulation. Intermittent and prolonged hemodiafiltration (HDF) has the depurative benefits of diffusion, plus the positive attributes of convection in a less expensive therapy. Aim: To report our experience with intermittent and prolonged on-line HDF in critically ill patients. Patients and Methods: During 2016, HDF therapies performed on critical patients with indication of renal replacement therapy were characterized. The hemodynamic profile was evaluated (doses of noradrenaline, blood pressure, heart rate and perfusion parameters). Results: Fifty-one therapies were performed in 25 critical patients, aged 58 ± 11 years (28% women), with an APACHE II score of 22.1 ±10. The average time of the therapies was 4.15 hours (range 3-8 hours), the replacement volume was 75 ± 18 mL/kg/h and ultrafiltration rate was 226 ± 207 mL/h. The mean initial, maximum and final noradrenaline doses were 0.07 ± 0.1, 0.13 ±0.18 and 0.09 ±0.16 μg/kg/min respectively. No differences between patients with low, medium and high doses of noradrenaline or dose increases during therapy, were observed. The greatest decrease in mean arterial pressure was 15.3% and the maximum increase in heart rate was 12.8%. Anticoagulation was not required in 88% of therapies. Conclusions: High-volume intermittent or prolonged HDF is an effective therapy in critical patients, with good hemodynamic tolerability, lower costs and avoidance of systemic anticoagulation risks.

Intermittent Convective Therapies in Patients with Acute Kidney Injury: A Systematic Review with Meta-Analysis

“…In all 4 RCTs, an open-label design was described. In the 4 observational studies, quality varied, where 2 studies can be categorized as low quality [22,29] and 2 as intermediate quality [1,24] according to the Newcastle-Ottawa Scale. Overall, the risk of bias of all observational studies [1,22,24,29] and 2 RCTs [23,28] was high.…”

“…Dialysis parameters administered were clearly defined for 3 studies [1,23,26], while only targeted parameters were mentioned for 4 studies [22,24,25,29] and were not detailed for one [28] (Table 1). No included study delivered the optimal convective volume (>23 L/session) in post-dilution HDF that was shown to be associated with reduced all-cause mortality in patients on maintenance dialysis [12].…”

“…Of these, 3,151 were excluded after screening titles and abstracts. A total of 10 unique studies were eligible after full-text screening [1,[21][22][23][24][25][26][27][28][29], from which 8 studies presented quantitative results for at least one prespecified outcome. The following outcomes were not mentioned in enough articles to allow a meta-analysis: length of stay, Kt/V urea , and intradialytic hypotension.…”

“…Filter Clotting Anticoagulation strategies were not specified for 5 of the 8 included studies. In the other 3 studies, anticoagulation usage varied from 11.3% for HDF sessions [22] to 100% for patients exposed to high-volume HF [26], using standard heparin [22,26], low-molecular weight heparin [25], or adapted regional citrate anticoagulation [26]. HD filter complete clotting occurred 21 times of 336 HDF sessions (6.25%) and 13 times of 255 HD sessions (5.1%) for Pettilä et al [25] (p = 0.55) and occurred in 1 of 51 sessions (2%) in the Barrios-Araya et al's [22] HDF cohort.…”

“…In the other 3 studies, anticoagulation usage varied from 11.3% for HDF sessions [22] to 100% for patients exposed to high-volume HF [26], using standard heparin [22,26], low-molecular weight heparin [25], or adapted regional citrate anticoagulation [26]. HD filter complete clotting occurred 21 times of 336 HDF sessions (6.25%) and 13 times of 255 HD sessions (5.1%) for Pettilä et al [25] (p = 0.55) and occurred in 1 of 51 sessions (2%) in the Barrios-Araya et al's [22] HDF cohort. Filter clotting leading to dialysis premature termination was also reported per patient in Skofic et al's [26] trial that compared high-volume pre-dilution HF (80 L/session, with anticoagulation) to HD, occurring at least once in 5.1% of patients from the HF group and 3.0% in the HD group (p = 0.38), totalizing 517 HF sessions and 710 HD sessions.…”