Intermittent hemodiafiltration as a down-step transition therapy in patients with acute kidney injury admitted to intensive care unit who initially underwent continuous venovenous hemodiafiltration

Abstract

Background/Aims: Continuous renal replacement therapies (CRRT) are initially employed in patients with acute kidney injury (AKI) in ICU setting. After the period of serious illness, hemodialysis is usually used as a mode of transition from CRRT. Intermittent hemodiafiltration (HDF) is not commonly applied in this scenario. Objectives: To evaluate the feasibility of using HDF as transition therapy after CVVHDF in critically patients with AKI. Methods: An observational and prospective pilot study was conducted in ICU patients with dialysis-requiring AKI. Patients were initially treated with CVVHDF and, after medical improvement, those who still needed renal replacement therapy were switched to HDF treatment. Results: Ten Patients underwent 53 HDF sessions (mean of 5.3 sessions/patient). The main cause of renal dysfunction was sepsis ( N = 7; 70%). The APACHE II mean score was 27.6 ± 6.9. During HDF treatment, the urea reduction ratio was 64.5 ± 7.5%, for β-2 microglobulin serum levels the percentage of decrease was 42.0 ± 7.8%, and for Cystatin C was 36.2 ± 6.9%. Five episodes of arterial hypotension occurred (9.4% of sessions). There were 20 episodes of electrolytic disturbance (37.7% of sessions), mainly hypophosphatemia. No pyrogenic or suggestive episode of bacteremia was observed. Conclusion: Hemodiafiltration was safe and efficient to treat critically ill patients with acute kidney injury during the transition phase from continuous to intermittent dialysis modality. Special attention should be paid regarding the occurrence of electrolytic disturbance, mainly hypophosphatemia.

Switching from continuous veno‐venous hemodiafiltration to intermittent sustained low‐efficiency daily hemodiafiltration (SLED‐f) in pediatric acute kidney injury: A prospective cohort study

“…SLED has been shown to be as efficient as CKRT in terms of fluid removal, mortality, hospital stay, and renal recovery in the recent meta‐analysis in adults 14 . While hybrid therapies such as SLED have been used in some institutions as a “de‐escalation” or “step‐down” therapy, it has not been established as a mainstream treatment 5,35,37 . Our study is a pioneer study looking at a selective population of transitioning CKRT to intermittent SLED‐ f therapy in children with multiple organ dysfunction syndrome.…”

“…There are limited adult studies and no pediatric studies describing the step‐down approach for CKRT 22,35 . PIKRT such as hemodiafiltration and Accelerated Venovenous Hemofiltration have been successfully used in transition from CKRT to intermittent hemodialysis in adults 22,35 .…”

“…There are limited adult studies and no pediatric studies describing the step‐down approach for CKRT 22,35 . PIKRT such as hemodiafiltration and Accelerated Venovenous Hemofiltration have been successfully used in transition from CKRT to intermittent hemodialysis in adults 22,35 . The study by Scherer et al showed the feasibility and benefits of step‐down therapy from continuous venovenous hemodiafiltration to intermittent hemodiafiltration in adults 35 .…”

“…Low molecular weight solute removal was assessed by urea reduction ratio and urea Kt/V. Urea Kt/V was calculated using Daugirdas formula 34–36 . Percent reduction of serum beta‐2 microglobulin was used as an adequacy marker of middle molecule clearance 34–36 .…”

Anticipation of recovery of native renal function and liberation from renal replacement therapy in critically ill patients with severe acute kidney injury

“…When dialysis is weaned, discontinued, or patients are transitioned to another RRT, there is a need to adapt drug dosing regimens (such as antibiotics) according to differences in pharmacokinetics and pharmacodynamics of the drugs [44]. Moreover, the switch of AKI-D patients to intermittent techniques may be associated with electrolyte imbalances [45] and more intradialytic hypotensive episodes and increased mortality [46]. Finally, patients with ESRD due to nonrecovery from AKI-D must be transitioned to IHD or CAPD prior to hospital discharge.…”