Continuous Renal Replacement Therapy for Critically Ill Patients: An Update

Abstract

Despite continuous progress in intensive care during the last decades, the outcome of critically ill patients in whom acute renal failure (ARF) develops is still poor. This outcome may be explained partially by the frequent occurrence of ARF as part of multiple organ systems failure (MOSF). In this complex and unstable patient population, the provision of adequate renal support with either intermittent hemodialysis or peritoneal dialysis may pose major problems. Continuous renal replacement therapy (CRRT) is now increasingly accepted as the preferred treatment modality in the management of ARF in these patients. The technique offers adequate control of biochemistry and fluid balance in hemodynamically unstable patients, thereby enabling aggressive nutritional and inotropic support without the risk of exacerbating azotemia or fluid overload. In addition, experimental and clinical data suggest that CRRT may have a beneficial influence on hemodynamics and gas exchange in patients with septic shock and (nonrenal) MOSF, independent of an impact on fluid balance. We review both technical and clinical aspects of various continuous therapies, including their impact on serum drug levels and nutrient balance. In addition, an attempt is made to clarify the possible beneficial role of CRRT in reducing patient morbidity and mortality in the ICU.

Preventing hypothermia during continuous veno‐venous haemodiafiltration: a randomized controlled trial

“…ICU patients lack the haemodynamic stability necessary to undergo the traditional forms of dialysis, which involve the exchange of large amounts of fluids over short periods of time. A better result, with fewer complications, is achieved through the use of continuous renal replacement therapy (CRRT), which involves a slower exchange of fluids over a continuous 24‐hour period (van Bommel et al. 1994, Holt et al.…”

Treatment of Life-Threatening Lithium Toxicity with High-Volume Continuous Venovenous Hemofiltration

“…It has already been suggested that the relatively slow, continous solute removal by continuous renal replacement therapy (CRRT) may be advantageous in severe intoxications of drugs with a large volume of distribution and a tendency to 'rebound' when removed by IHD [6]. Nowadays, expertise with CRRT is readily available in many ICUs [7].…”

The diagnosis of acute renal failure in intensive care: mongrel or pedigree?

“… Patients who recover from renal failure but still go on to die in ITU may be misclassified as having died with ARF. Other evolving demographics may also be relevant. The continued high mortality over the last 10–20 years may be due to the ITU patient population now being older [12, 32, 35, 48], having an increased incidence of sepsis and MOF [12, 20], having more associated comorbidity [18, 48] and the observation that more invasive surgery is being extended to an older, more unfit population [16, 49]. …”

“…Acute renal failure seldom occurs in isolation and is usually associated with MOF [1, 4–6, 12, 14, 17, 18, 27, 29, 38, 49, 55].…”

“… Acute renal failure seldom occurs in isolation and is usually associated with MOF [1, 4–6, 12, 14, 17, 18, 27, 29, 38, 49, 55]. Mortality is related to the aetiology more than to the presence of ARF. Patients with ARF and MOF have a much higher mortality (63–80%) [21, 24, 32] when compared to the 38% mortality [28] in those patients with isolated ARF even if it required RRT. …”