Use of Continuous Haemodiafiltration: An Approach to the Management of Acute Renal Failure in the Critically

Abstract

We have prospectivly investigated the effect of a flexible approach to the management of acute renal failure in critically ill patients based on continuous haemodiafiltration (CHD). Fifty critically ill patients (mean APACHE II score 28.1, range 18-37), with a mean age of 59.5 years, were treated with continuous arteriovenous haemodiafiltration (CAVHD) and/or continuous venovenous haemodiafiltration (CWHD). CHD achieved excellent haemodynamic stability and control of azotaemia in all patients and permitted aggressive parenteral nutrition. The mean blood urea concentration fell from 33.9 mmol/l (95% confidence interval, CI, 29.1-38.7) to a plateau of 17 mmol/l (95% CI 14.3-19.7) after 72 h of therapy despite persistent anuria and the parenteral administration of 0.3g/kday of protein nitrogen (mean urea clearance: 24.2ml/min; 95% CI 22.9-25.5). No supplemental dialytic therapy was required during the 9,485 h of treatment. All clinically significant complications related to vascular access (14%). Twenty-two patients (44%) survived to be discharged from the ICU. CHD is relatively safe and effective in the management of acute renal failure in the critically ill.

Does continuous renal replacement therapy favourably influence the outcome of the patients?

“…Possibly, there is an increased frequency of access related complications [3]. Furthermore, once very simple and possibly the cheapest form of RRT, todays continuous methods include highly sophisticated treatment devices to guarantee treatment safety and are thought to be some 2.5 times more expensive than conventional intermittent dialysis and/or haemofiltration [8,9]. This difference might even be more pronounced if one considers the additional manpower required.…”

“…Studies reporting patients on a continuous form of renal replacement therapy without a control group An additional 52 studies describing only patients treated with continuous RRT without an intermittently treated control group were found in the literature [2,6,9,. The number of patients included in the reported studies ranged from five [23] to 255 [70] patients.…”

“…Treatment modalities included continuous haemofiltration, either arteriovenous [23,26,28-32,37,45,-46,50-53,59], venovenous [36,38,47,49,60,66] or both [34,35,44,55], slow continuous ultrafiltration [6], continuous haemodialysis, either arteriovenous [39,41,54,56,58,61,65,68], venovenous [25,31] or both [9,24,42,62,63], continuous haemodiafiltration [40,48,67,69] as well as both continuous arteriovenous haemofiltration and haemodialysis [43,57] respectively. In one study continuous RRT was combined with intermittent haemodialysis [29].…”

“…The types of niters used were mostly polyacrylonitrile [9,24,25,28,31,[33][34][35][37][38][39][40][41][42]48,53,58,61,65,66,[68][69][70], but also polysulphone [6,23,26,30,31,36,43,[49][50][51]57] or polyamide [32,44,46,47,51,55,56,58,70] niters have been used. In some studies the type of filter prescribed was not indicated.…”

“…Mean APACHE II scores were available from 12 studies only [9,24,25,[33][34][35]39,58,59,61,64,66]. The reported values were between 21 [46,59] and 33 [39].…”