SEARCH · PubMed Health

Results for “Renal Replacement Therapy”

Explore indexed PubMed citations for clinical trials, systematic reviews and public health research. Read source abstracts and follow each citation to its original PubMed record.

Quote a phrase for an exact phrase match. Source license links do not imply unrestricted reuse.

At least 19 recordsLinked to original sources

PubMed1997

[Choice of renal replacement therapy].

Renal replacement therapies (RRT) for acute renal failure patients consist of continuous or intermittent methods. Continuous renal replacement therapies (CRRT) are used in 54% of centers. Determinant for the choice of the continuous versus intermittent method is the clinical status of the patients. Those who are hemodynamically unstable, who receive a large fluid intake, who are anuric, who present with severe and persistent metabolic disorders such as acidosis or hyperkaliemia, and who are in respiratory failure, are preferably treated with CRRT. Once the patient has improved, he can be switched to intermittent RRT (IRRT). Thus CRRT and IRRT are complementary approaches. Dialysis material should be biocompatible; the RRT method used should guarantee stable hemodynamics. Coping with these two requirements reduces the time duration of renal recovery, diminishes the need for catecholamines and may improve the survival rate.

Acute Kidney Injury↗

PubMed2002

Racial disparities in renal replacement therapy.

Renal replacement therapy (RRT)--encompassing hemodialysis, peritoneal dialysis, and kidney transplantation--provides life-sustaining treatment for the expanding end-stage renal disease (ESRD) population. There is an excess burden of ESRD in African-American, Hispanic, Native Americans, and Asian/Pacific Islanders. Moreover, there is mounting evidence to suggest that significant racial and ethnic disparities exist in RRT--including referral and initiation of dialysis, adequacy of dialysis, and anemia management--with non-white patients usually at a disadvantage. In addition, there are cultural and sociodemographic differences that lead to racial variation in the choice of ESRD modality. Lastly, in certain ethnic ESRD populations, there are a series of complex issues, from biologic to socioeconomic, which limit kidney transplantation--the treatment of choice. Despite these inequalities, which are often associated with negative outcomes, these non-white groups have better hemodialysis survival rates than white patients. It is essential to develop strategies to address the disparities in ESRD treatment among minority groups in order to minimize the differences in RRT provision and identify the factors that confer improved dialysis survival-thus improving care for all Americans with kidney disease.

Anemia↗

PubMed2002

Clinical characterization of a new polymeric membrane for use in renal replacement therapy.

Renal replacement therapy makes extensive use of semi-permeable membranes, ideal requirements for such membranes are good solute transport characteristics and a low reactivity with blood. Membranes manufactured from synthetic polymers fulfil these requirements. Such membranes have asymmetric and anisotropic structures characterized by a dense layer with which the blood is in contact supported by a thicker solid structure with containing interlinked voids, providing support. The nature of the structures are critically dependent upon the polymer blend and the control of parameters during manufacture such as the temperature or additive concentrations. In this prospective study, we have evaluated the clinical performance of a new membrane manufactured from a blend of polyamide, polyarylethersulfone and polyvinylpyrrolidone (Polyflux, Gambro GmbH, Hechingen, Germany), and compared it with that of polysulfone blended with polyvinylpyrrolidone (Fresenius Polysulfone, Fresenius Medical Care, Bad Homburg, Germany), a material widely acknowledged as providing an optimal biocompatibility in terms of solute removal and complement activation. The clearance of small molecules (urea, creatinine, phosphate) for both membranes was comparable. Both membranes removed beta2 microglobulin during treatment (50.2% reduction with Polyflux and 54.5% reduction with polysulfone. This removal due to the non-selectivity of the membranes was associated with protein loss during therapy which was similar for both the membranes (7.7 g). The biocompatibility profiles of the membranes indicated slight neutropenia and platelet adhesion and minimal C3a, C5a and SC5b-9 generation which were independent of the membrane material. These findings indicate that despite the differences in microstructure of the membranes, their functional performance in the clinical setting is comparable.

Anisotropy↗

PubMed1998

Cost of renal replacement therapy.

Renal replacement therapy (RRT) now sustains an older, medically complicated population, reducing dependency on haemodialysis. Costing focuses on avoidable treatment costs, e.g. late referral for management and inappropriate placement on a RRT modality because of restricted local options. Sound regional plans need to be implemented so that patients can be appropriately treated.

Cost-Benefit Analysis↗

PubMed1992

Reappraisal of long-term renal replacement therapy. Renal transplantation: medical versus statistical approach.

The validity of the numerous statistical methods used for the assessment of the results achieved with renal transplantation performed for terminally uremic patients may be challenged by a medicalized approach of the patient's post transplantation course and outcome. This assumption has been applied to a population of 700 patients who received a grafted kidney in our unit between November 1972 and December 1990. Among 77 patients who had been followed up for 10-15 years after grafting, 75% had not suffered any serious related complication during the first decade after transplantation. In contrast, among the whole transplant population, transplantation entailed either a rapidly fatal issue due to an unpredictable and irreversible complication in 45 patients (6.4%), or a state of chronic illness with severely disabling complications in 150 others (21.5%). At present, the main cause of concern remains, however, the persistent long-term graft loss due to chronic rejection. Nevertheless, the advances and results achieved in the field of organ transplantation in recent years justifies the policy which privileges renal transplantation as the first-choice method of renal replacement therapy for every terminally uremic patient aged less than 60-65 years in whom careful workup does not reveal any clinical/psychological contraindication.

Actuarial Analysis↗

PubMed2006

Challenges and future of renal replacement therapy.

Renal community increasingly recognizes the challenges of very high mortality, morbidity and low quality of life among dialysis patients. Current hemodialysis (HD) schedule provides less than 10% of the clearance power of the natural kidneys and therefore current standard HD treatment is still a long way from providing adequate renal replacement. In the future it would be expected to improve dialysis control with the development of new technology: membranes, dialysate buffer, electrolyte concentration, system interface, arteriovenous access monitoring. Online technology must be adapted to routine HD for new prescription monitoring such as creatinine online sensing technology, sodium-specific electrode or hydrogen ion concentration. Online convective therapies offer the opportunity for a more biological renal replacement therapy increasing convective transport in order to "reproduce" glomerular function and improving small and middle molecular clearance in an economically feasible and safe way. The paradigm of thrice-weekly dialysis is faced with diminishing returns, with the possible exception of long dialysis sessions. More frequent (daily) dialysis represents a very promising tool for improving dialysis outcomes and quality of life. Future technologies for renal replacement include bioartificial kidneys based in continuous hemofiltration and bioartificial tubules. Although Phase I/II clinical trial on 10 patients with acute renal failure has been reported the procedure requires further evaluation. Organogenesis, therapeutic cloning, or cloning and organogenesis combined might in the future produce a functional and histocompatible kidney. The continuous increase in incidence and prevalence of renal-replacement therapy is a world-wide phenomenon, although the rates in Europe are still much lower than in the U.S. The increase in rates applies especially to older patients, patients with diabetes mellitus and renal vascular disease and the consequences of this important comorbidity are very important in terms of mortality.

Forecasting↗

PubMed2002

Acute renal failure and multiple organ dysfunction in the ICU: from renal replacement therapy (RRT) to multiple organ support therapy (MOST).

Renal replacement therapy (RRT) has evolved from the concept that we need to treat the dysfunction of a single organ (the kidney). As intensive care units have become more and more complex, it has become clear that the majority of patients with acute renal failure often have dysfunction of several other organs. In order to facilitate single organ support in this setting, continuous renal replacement therapy (CRRT) techniques have been developed. However, CRRT has opened the door to the concept that targeting renal support as the only goal of extracorporeal blood purification may be a simplistic view of our therapeutic aims. In this article we argue that it is now time to move from the simple goal of achieving adequate renal support. The proper goal of extracorporeal blood purification in ICU should be multi-organ support therapy (MOST). We explain why MOST represents the most logical future conceptual and practical evolution of CRRT and illustrates the biological rationale, supplying animal and clinical evidence that confirms the need to move rapidly in this direction theoretically, practically and technologically.

Acute Kidney Injury↗

PubMed2005

Renal replacement therapy and the kidney: minimizing the impact of renal replacement therapy on recovery of acute renal failure.

PURPOSE OF REVIEW: Although renal replacement therapy is the mainstay of supportive care in patients with severe acute renal failure, its performance can have untoward effects that contribute to the prolongation of renal failure or impede the ultimate recovery of renal function. In this review, we categorize the major complications associated with renal replacement therapy and assess their impact on recovery of renal function. RECENT FINDINGS: The major mechanisms by which renal replacement therapy is postulated to delay renal recovery include treatment-associated hemodynamic instability, vascular catheter-related bacteremia and sepsis, and cytokine activation by bioincompatible membranes. Clinical data regarding the role of dialysis catheter infections in delay of renal recovery are lacking. The data regarding the role of membrane biocompatibility and the modality and dose of renal replacement therapy are limited and conflicting. SUMMARY: Clinical recommendations must be limited to the broad admonishment that complications during renal replacement therapy, including hemodynamic instability and catheter-related bacteremia, be minimized by using best clinical practices, while recognizing that the impact of specific practices on recovery of renal function have not been evaluated. The data do not support recommendations regarding utilization of specific membranes or the modality or dose of renal replacement therapy on the basis of their impact on recovery of renal function.

Acute Kidney Injury↗

PubMed2006

Survival to discharge among patients treated with continuous renal replacement therapy.

Continuous renal replacement therapy (CRRT) is widely used in critically ill patients with acute renal failure (ARF). The survival of patients who require CRRT and the factors predicting their outcomes are not well defined. We sought to identify clinical features to predict survival in patients treated with CRRT. We reviewed the charts of all patients who received CRRT at the Toronto General Hospital during the year 2002. Our cohort (n=85) represented 97% of patients treated with this modality in 3 critical care units. We identified demographic variables, underlying diagnoses, transplantation status, location (medical-surgical, coronary, or cardiovascular surgery intensive care units), CRRT duration, baseline estimated glomerular filtration rate (eGFR), and presence of oliguria (<400 mL/day) on the day of CRRT initiation. The principal outcome was survival to hospital discharge. Among those alive at discharge, we assessed whether there was an ongoing need for renal replacement therapy. Greater than one-third (38%, 32/85) of patients survived to hospital discharge. Three (9%) survivors remained dialysis-dependent at the time of discharge. Survivors were younger than nonsurvivors (mean age 56 vs. 60 years), were on CRRT for a shorter duration (7 vs. 13 days), and had a higher baseline eGFR (74 vs. 62 mL/min/m(2)). Patient survival varied among different critical care units (medical surgical 33%, coronary 38%, and cardiovascular surgery 45%). Multivariable logistic regression revealed that shorter duration of CRRT, nonoliguria, and baseline eGFR >60 mL/min/m(2) were independently associated with survival to hospital discharge (p<0.05). Critically ill patients with ARF who require CRRT continue to have high in-hospital mortality. A shorter period of CRRT dependence, nonoliguria and higher baseline renal function may predict a more favorable prognosis. The majority of CRRT patients who survive their critical illness are independent of dialysis at the time of hospital discharge.

Adult↗

PubMed2005

Continuous renal replacement therapy improves renal recovery from acute renal failure.

BACKGROUND: Acute renal failure (ARF) occurs in up to 10% of critically ill patients, with significant associated morbidity and mortality. The optimal mode of renal replacement therapy (RRT) remains controversial. This retrospective study compared continuous renal replacement therapy (CRRT) and intermittent hemodialysis (IHD) for RRT in terms of intensive care unit (ICU) and hospital mortality, and renal recovery. METHODS: We reviewed the records of all patients undergoing RRT for the treatment of ARF over a 12-month period. Patients were compared according to mode of RRT, demographics, physiologic characteristics, and outcomes of ICU and hospital mortality and renal recovery using the Chi square, Student's t test, and multiple logistic regression as appropriate. RESULTS: 116 patients with renal insufficiency underwent RRT during the study period. Of these, 93 had ARF. The severity of illness of CRRT patients was similar to that of IHD patients using APACHE II (25.1 vs 23.5, P = 0.37), but they required significantly more intensive nursing (therapeutic intervention scale 47.8 vs 37.6, P = 0.0001). Mortality was associated with lower pH at presentation (P = 0.003) and increasing age (P = 0.03). Renal recovery was significantly more frequent among patients initially treated with CRRT (21/24 vs 5/14, P = 0.0003). Further investigation to define optimal timing, dose, and duration of RRT may be beneficial. CONCLUSIONS: Although further study is needed, this study suggests that renal recovery may be better after CRRT than IHD for ARF. Mortality was not affected significantly by RRT mode.

Acute Kidney Injury↗

PubMed2002

Urea kinetics during sustained low-efficiency dialysis in critically ill patients requiring renal replacement therapy.

Continuous renal replacement therapies have practical and theoretical advantages compared with conventional intermittent hemodialysis in hemodynamically unstable or severely catabolic patients with acute renal failure (ARF). Sustained low-efficiency dialysis (SLED) is a hybrid modality introduced July 1998 at the University of Arkansas for Medical Sciences that involves the application of a conventional hemodialysis machine with reduced dialysate and blood flow rates for 12-hour nocturnal treatments. Nine critically ill patients with ARF were studied during a single SLED treatment to determine delivered dialysis dose and the most appropriate model for the description of urea kinetics during treatment. Five patients were men, mean Acute Physiology and Chronic Health Evaluation (APACHE) II score was 28.9 and mean weight was 92.5 kg. Kt/V was determined by the reference method of direct dialysate quantification (DDQ) combined with an equilibrated postdialysis plasma water urea nitrogen (PUN) concentration and four other methods that were either blood or dialysate based, single or double pool, or model independent (whole-body kinetic method). Solute removal indices (SRIs) were determined from net urea removal and urea distribution volume supplied from DDQ (reference method) and by mass balance using variables supplied from blood-based formal variable-volume single-pool (VVSP) urea kinetic modeling. Equivalent renal urea clearances (EKRs) were calculated from urea generation rates and time-averaged concentrations for PUN based on weekly mass balance with kinetic variables supplied by either DDQ (reference method) or formal blood-based VVSP modeling. Mean Kt/V determined by the reference method was 1.40 and not significantly different when determined by formal VVSP modeling, DDQ using an immediate postdialysis PUN, or the whole-body kinetic method. Correction of single-pool Kt/V by a Daugirdas rate equation did not yield plausible results. Mean SRI and EKR by the reference methods were 0.61 and 24.8 mL/min, respectively, and not significantly different when determined by blood-based methods. A single-pool urea kinetic model adequately described intradialytic PUN profiles, indicating that SLED was associated with minimal urea disequilibrium. This was supported by the parity between hemodialyzer and whole-body urea clearances, and the mean postdialytic urea rebound of 4.1% (P = 0.13 versus zero). Additional prospective studies are needed in this setting to define the optimal method for dialysis quantification, targets for azotemic control, and optimal modality of renal replacement therapy. In conclusion, SLED delivers a high dose of dialysis with minimal associated urea disequilibrium and can be quantified by Kt/V, SRI, and EKR from blood-based methods using single-pool urea kinetic models.

Acute Kidney Injury↗

PubMed2006

Medication errors and patient complications with continuous renal replacement therapy.

Continuous renal replacement therapy (CRRT) is commonly used for renal support in the intensive care unit. While the risk of medication errors in the intensive care unit has been described, errors related specifically to CRRT are unknown. The purpose of this study is to characterize medication errors related to CRRT and compare medication errors that occur with manually compounded solutions versus commercially available solutions. We surveyed three separate internet-based, pediatric list serves that are commonly used for communications for programs utilizing CRRT. Data regarding CRRT practices and medication errors were recorded. Medication errors were graded for degree of severity and compared between programs using manually compounded dialysis solutions versus commercially available dialysis solutions. In a survey with 31 program responses, 18 reported medication errors. Two of the 18 were related to heparin compounding, while 16/18 were due to solution compounding errors. Half of the medication errors were classified as causing harm, two of which were fatal. All medication errors were reported by programs that manually compounded their dialysis solutions. Medication errors related to CRRT are associated with a high degree of severity, including death. Industry-based, commercially available solutions can decrease the occurrence of medication errors due to CRRT.

Child↗

PubMed2001

Anticoagulation in continuous renal replacement therapy.

Continuous renal replacement therapy (CRRT) is a specialized intervention that is managed largely by critical care nurses who are educated in the theoretical and practical aspects of the therapy. CRRT is most commonly indicated for hemodynamically unstable patients who have acute renal failure and a narrow margin of tolerance for the rapid fluid shifts associated with traditional dialysis. Although the utilization of CRRT in the critical care setting is becoming more widespread, numerous factors need to be considered before therapy is initiated. The use of anticoagulation is a concern because of the associated risk of bleeding and thrombocytopenia. Nurses at the bedside must be expert in both managing CRRT and assisting in identifying patients who may be at potential risk when this form of treatment is in place. An overview of possible anticoagulants for use in CRRT is outlined in this article.

Anticoagulants↗

PubMed2002

Acid-base and electrolyte management in continuous renal replacement therapy.

Continuous renal replacement techniques are often utilized to manage acid-base and electrolyte problems in the critically ill patient. These techniques have an inherent capacity to manipulate the plasma composition and can be utilized efficiently to maintain homeostasis and metabolic control. Unfortunately, the efficacy of these techniques also permits wide variation in their use and can result in complications if they are not used appropriately. In most instances complications can be prevented by recognition of the operating principles and careful attention to detail. This article provides an overview of the principles of acid-base and electrolyte management with continuous renal replacement therapy.

Acid-Base Equilibrium↗

PubMed1999

Metabolic aspects of continuous renal replacement therapies.

Continuous renal replacement therapies (CRRTs) are associated with a broad pattern of additional metabolic effects beyond renal detoxification. Because of the continuous mode of therapy and the high fluid turnover usually associated with CRRTs, these side effects can become clinically relevant. With many CRRT systems currently used, heat loss is considerable, but CRRTs can also be used to modulate body temperature in hyperpyretic patients. Inappropriate glucose concentrations of some substitution fluids can result in excessive glucose intake. Most substitution and/or dialysate fluids used for CRRTs contain lactate as organic anion. In disease states with impaired lactate utilization, such as acute or chronic liver failure, and/or with increased endogenous lactate formation such as in shock states, this can result in hyperlactemia and is potentially associated with various adverse side effects. Small molecular weight substances such as amino acids or water-soluble vitamins are lost in relevant amounts. With convective clearance and the high molecular cut-off of synthetic membranes, medium-sized molecules such as hormones and cytokines are also filtered, but the pathophysiologic relevance of this observation remains to be specified. Moreover, synthetic membranes used for CRRTs have adsorptive properties for a variety of molecules, such as cytokines, complement factors, and endotoxin. Continuous blood membrane interactions cause the phenomena of bioincompatibility and a low-grade inflammatory reaction with potentially adverse consequences on protein metabolism and immunocompetence. In designing a nutritional program for a patient on CRRT, these metabolic effects--especially the loss of nutritional substrates--must be considered. Certainly, most of these side effects, such as the excessive load of lactate or the loss of nutrients, are undesirable. However, some side effects, such as the modulation of body temperature and the elimination of endotoxin and/or mediators, might be at least potentially beneficial.

Acute Kidney Injury↗

PubMed2005

Antibiotic dosing in critically ill adult patients receiving continuous renal replacement therapy.

Continuous renal replacement therapy (CRRT) is now commonly used as a means of support for critically ill patients with renal failure. No recent comprehensive guidelines exist that provide antibiotic dosing recommendations for adult patients receiving CRRT. Doses used in intermittent hemodialysis cannot be directly applied to these patients, and antibiotic pharmacokinetics are different than those in patients with normal renal function. We reviewed the literature for studies involving the following antibiotics frequently used to treat critically ill adult patients receiving CRRT: vancomycin, linezolid, daptomycin, meropenem, imipenem-cilastatin, nafcillin, ampicillin-sulbactam, piperacillin-tazobactam, ticarcillin-clavulanic acid, cefazolin, cefotaxime, ceftriaxone, ceftazidime, cefepime, aztreonam, ciprofloxacin, levofloxacin, moxifloxacin, clindamycin, colistin, amikacin, gentamicin, tobramycin, fluconazole, itraconazole, voriconazole, amphotericin B (deoxycholate and lipid formulations), and acyclovir. We used these data, as well as clinical experience, to make recommendations for antibiotic dosing in critically ill patients receiving CRRT.

Anti-Bacterial Agents↗

PubMed2003

Renal failure and renal replacement therapy.

Continuous renal replacement therapy is an effective means for fluid and solute management in ARF/MOSF. Prospective studies have examined issues of anticoagulation, the impact of replacement/dialysis, the effects of bicarbonate-versus lactate-based solutions, and nutritional and medication clearance. Speculation and bias exists concerning when and for what indications CRRT should be initiated. Many clinicians, supported by data from Ronco and Goldstein, would contest that early institution is better if the risks (eg, access, anticoagulation) are minimal and the possible benefits are maximal. The authors, examining the issues as an intensivist and as a nephrologist, believe that early institution, aggressive replacement/dialysis, and use of citrate-based replacement fluids provide substantive advantages. With the advent of Ronco's recent data on sepsis managed with filtration and plasma absorption, the indication for use of CRRT in MOSF may become more evident regardless of the presence or absence of ARF.

Acute Kidney Injury↗

PubMed1996

Protein losses in continuous renal replacement therapies.

Continuous renal replacement therapy (CRRT) has become a popular treatment modality but may have the disadvantage of producing substantial protein losses. With use of the Biuret method, a relatively insensitive assay, dialysate/ultrafiltrate protein losses have been reported to be as high as 1.3 g/L. With CRRT outputs of up to 50 L/day, these values would amount to protein losses of up to 65 g/day. In this study, dialysate/ultrafiltrate protein losses were reanalyzed by using a highly sensitive microprotein reagent (pyrogallol red) considered to be more accurate than previously available methods. Twenty-two dialysate/ultrafiltrate samples were obtained from Amicon-20 Diafilters or Fresenius F-80 dialyzers during continuous venovenous hemofiltration (CVVH) or continuous venovenous hemodialysis/hemodiafiltration (CVVHD/F). Mean hourly output for all treatments was 1637 +/- 694 mL/h. Mean protein concentration for all 22 dialysate/ultrafiltrate samples was 4.2 +/- 4.0 mg/dL. Mean dialysate/ultrafiltrate protein concentrations were similar for the Amicon 20 (3.4 +/- 4.4 mg/dL, N = 9) and the Fresenius F-80 (4.7 +/- 3.9 mg/dL, N = 13) (P = not significant). Protein losses were higher during convection-based CVVH (6.0 +/- 5.1 mg/dL, N = 10; range, 1 to 15 mg/dL) than during the mixed convection and diffusion-based CVVHD/F (2.7 +/- 1.9 mg/dL, N = 12; range, 0 to 6 mg/dL) (P = 0.049). Mean serum protein concentration at the time of dialysate/ultrafiltrate sampling was 4.7 +/- 1.8 g/dL. There was a weak, but statistically significant correlation between the dialysate/ultrafiltrate samples and the corresponding value for serum protein (r = 0.468, P < 0.03). It was concluded that protein losses during CRRT treatments are substantially lower than previously reported, are dependent on the serum protein concentration and the predominant nature of solute removal (convection versus diffusion), and can vary between 1.2 and 7.5 g/day.

Blood Proteins↗