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Kitchlu A, Adhikari N, Burns KEA, Friedrich JO, Garg AX, Klein D, Richardson RM, Wald R. Outcomes of sustained low efficiency dialysis versus continuous renal replacement therapy in critically ill adults with acute kidney injury: a cohort study. BMC Nephrol 2015; 16:127. [PMID: 26238520 PMCID: PMC4522955 DOI: 10.1186/s12882-015-0123-4] [Citation(s) in RCA: 40] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2014] [Accepted: 07/24/2015] [Indexed: 11/10/2022] Open
Abstract
Background Sustained low efficiency dialysis (SLED) is increasingly used as a renal replacement modality in critically ill patients with acute kidney injury (AKI) and hemodynamic instability. SLED may reduce the hemodynamic perturbations of intermittent hemodialysis, while obviating the resource demands of CRRT. Although SLED is being increasingly used, few studies have evaluated its impact on clinical outcomes. Methods We conducted a cohort study comparing SLED (target 8 h/session, blood flow 200 mL/min, predominantly without anticoagulation) to CRRT in four ICUs at an academic medical centre. The primary outcome was mortality 30 days after RRT initiation, adjusted for demographics, comorbidity, baseline kidney function, and Sequential Organ Failure Assessment score. Secondary outcomes were persistent RRT dependence at 30 days and early clinical deterioration, defined as a rise in SOFA score or death 48 h after starting RRT. Results We identified 158 patients who initiated treatment with CRRT and 74 with SLED. Mortality at 30 days was 54 % and 61 % among SLED- and CRRT-treated patients, respectively [adjusted odds ratio (OR) 1.07, 95 % CI 0.56–2.03, as compared with CRRT]. Among SLED recipients, the risk of RRT dependence at 30 days (adjusted OR 1.36, 95 % CI 0.51–3.57) and early clinical deterioration (adjusted OR 0.73, 95 % CI 0.40–1.34) were not different as compared to patients who initiated CRRT. Conclusions Notwithstanding the limitations of this small non-randomized study, we found similar clinical outcomes for patients treated with SLED and CRRT. While we await the completion of a trial that will definitively assess the non-inferiority of SLED as compared to CRRT, SLED appears to be an acceptable alternative form of renal support in hemodynamically unstable patients with AKI. Electronic supplementary material The online version of this article (doi:10.1186/s12882-015-0123-4) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Abhijat Kitchlu
- Department of Medicine, Division of Nephrology, University of Toronto, Toronto, ON, Canada.
| | - Neill Adhikari
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada. .,Department of Critical Care Medicine and Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
| | - Karen E A Burns
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada. .,Li Ka Shing Knowledge Institute of St. Michael's Hospital, 61 Queen Street East, 9-140, Toronto, ON, M5C 2 T2, Canada. .,Departments of Critical Care and Medicine, St. Michael's Hospital, Toronto, ON, Canada.
| | - Jan O Friedrich
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada. .,Li Ka Shing Knowledge Institute of St. Michael's Hospital, 61 Queen Street East, 9-140, Toronto, ON, M5C 2 T2, Canada. .,Departments of Critical Care and Medicine, St. Michael's Hospital, Toronto, ON, Canada.
| | - Amit X Garg
- Division of Nephrology, Department of Medicine, University of Western Ontario, London, ON, Canada. .,Department of Epidemiology & Biostatistics, University of Western Ontario, London, ON, Canada.
| | - David Klein
- Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada. .,Li Ka Shing Knowledge Institute of St. Michael's Hospital, 61 Queen Street East, 9-140, Toronto, ON, M5C 2 T2, Canada. .,Departments of Critical Care and Medicine, St. Michael's Hospital, Toronto, ON, Canada.
| | - Robert M Richardson
- Department of Medicine, Division of Nephrology, University of Toronto, Toronto, ON, Canada.
| | - Ron Wald
- Department of Medicine, Division of Nephrology, University of Toronto, Toronto, ON, Canada. .,Li Ka Shing Knowledge Institute of St. Michael's Hospital, 61 Queen Street East, 9-140, Toronto, ON, M5C 2 T2, Canada.
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Takahashi H, Sakai R, Fujita A, Kuwabara H, Hattori Y, Matsuura S, Ohshima R, Hagihara M, Tomita N, Ishigatsubo Y, Fujisawa S. Concentrated Ascites Reinfusion Therapy for Sinusoidal Obstructive Syndrome After Hematopoietic Stem Cell Transplantation. Artif Organs 2013; 37:932-6. [DOI: 10.1111/aor.12080] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Affiliation(s)
| | | | - Atsuko Fujita
- Department of Hematology; Yokohama City University Medical Center; Yokohama; Japan
| | - Hideyuki Kuwabara
- Department of Hematology; Yokohama City University Medical Center; Yokohama; Japan
| | - Yukako Hattori
- Department of Hematology; Yokohama City University Medical Center; Yokohama; Japan
| | - Shiro Matsuura
- Department of Hematology; Yokohama City University Medical Center; Yokohama; Japan
| | - Rika Ohshima
- Department of Hematology; Yokohama City University Medical Center; Yokohama; Japan
| | - Maki Hagihara
- Department of Hematology; Yokohama City University Medical Center; Yokohama; Japan
| | - Naoto Tomita
- Department of Internal Medicine and Clinical Immunology; Yokohama City University Graduate School of Medicine; Yokohama; Japan
| | - Yoshiaki Ishigatsubo
- Department of Internal Medicine and Clinical Immunology; Yokohama City University Graduate School of Medicine; Yokohama; Japan
| | - Shin Fujisawa
- Department of Hematology; Yokohama City University Medical Center; Yokohama; Japan
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Yevzlin AS, Humes HD. Cell therapy, advanced materials, and new approaches to acute kidney injury. Hosp Pract (1995) 2012; 37:137-43. [PMID: 20877182 DOI: 10.3810/hp.2009.12.267] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Acute renal failure (ARF) is a common clinical syndrome characterized by an abrupt deterioration in kidney function, resulting in abnormalities in volume-regulatory, metabolic-regulatory, excretory, and endocrine functions. Despite decades of improvements in the provision of intensive care, and specifically in the provision of renal replacement therapy, the morbidity and mortality associated with acute kidney injury (AKI) remain extremely high. This article highlights novel cell therapies, advanced materials, and approaches to AKI with the aim of illuminating a potential path for future basic, translational, and clinical research using these novel modalities.
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Affiliation(s)
- Alexander S Yevzlin
- Department of Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53713, USA.
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Kimura Y, Ohba K, Sumida H, Tsujita K, Hirose T, Maruyama H, Hirai S, Kaikita K, Hokimoto S, Sugiyama S, Ogawa H. A survival case of cardiogenic shock due to left main coronary artery myocardial infarction: successful cooperation with on-site percutaneous coronary intervention and helicopter emergency medical service. Intern Med 2012; 51:1845-50. [PMID: 22821098 DOI: 10.2169/internalmedicine.51.7442] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A 54-year-old man was referred to a local hospital, located about 90 km from our hospital, with cardiogenic shock due to left main coronary artery infarction (LMCA-MI). Percutaneous coronary intervention (PCI) was performed under intra-aortic balloon pumping (IABP) support, but resulted in insufficient reperfusion and his condition worsened. The helicopter emergency medical service (HEMS) rapidly transported the patient to our hospital. After percutaneous cardio-pulmonary support system (PCPS) insertion, PCI could establish the coronary flow. A series of intensive therapies saved the patient. The cooperation of medical and emergency service system following revascularization and intensive care saved the patient with LMCA-MI accompanied by cardiogenic shock.
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Affiliation(s)
- Yuichi Kimura
- Department of Cardiovascular Medicine, Graduate School of Medical Sciences, Kumamoto University, Japan
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Davies HT, Leslie GD. Intermittent versus continuous renal replacement therapy: a matter of controversy. Intensive Crit Care Nurs 2008; 24:269-85. [PMID: 18394900 DOI: 10.1016/j.iccn.2008.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2007] [Revised: 01/15/2008] [Accepted: 02/17/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND Acute Renal Failure (ARF) requiring some form of replacement therapy is a frequent complication in the critically ill patient. Despite potential therapeutic advantages the expectation of an improvement in patient outcomes using Continuous Renal Replacement Therapy (CRRT) compared to conventional Intermittent Haemodialysis (IHD) remains controversial. AIMS AND METHOD This article will review the literature on the issues surrounding the use of IHD versus CRRT in the management of the critically ill patient. Articles were selected according to level of evidence with priority given to meta-analyses and randomised controlled trials. DISCUSSION Several operational features of CRRT allow this technique to be tolerated more easily in critical illness than IHD. The gradual removal of fluid reduces the incidence of hypotension and the risk of volume overload. Decreased variability in the concentration of solutes enables greater azotemia control. However, CRRT is required to operate uninterrupted to achieve a treatment dose that is equivalent to a conventional IHD treatment schedule. In the absence of definitive evidence to validate superior patient survival and return of renal function there is disagreement as to the most appropriate form of Renal Replacement Therapy (RRT) for the critically ill patient. The introduction of 'hybrid' therapies offers a further alternative treatment strategy, which combine favourable aspects of IHD and CRRT. CONCLUSION The decision to use IHD or CRRT should be guided by the therapeutic needs of the patient rather than the operational differences between the two techniques. The resources and expertise available at the organisation are also important in determining the mode best able to manage the critically ill patient at any stage and may change according to the severity of illness. The emergence of hybrid therapies provides a compromise option which encompasses many of the features of both systems, but does not embrace all options of either approach.
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Affiliation(s)
- Hugh T Davies
- Intensive Care Unit, Royal Perth Hospital, Curtin University of Technology, Western Australia, Australia.
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Tolwani AJ, Campbell RC, Stofan BS, Lai KR, Oster RA, Wille KM. Standard versus high-dose CVVHDF for ICU-related acute renal failure. J Am Soc Nephrol 2008; 19:1233-8. [PMID: 18337480 DOI: 10.1681/asn.2007111173] [Citation(s) in RCA: 170] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
The effect of dosage of continuous venovenous hemodiafiltration (CVVHDF) on survival in patients with acute renal failure (ARF) is unknown. In this study, 200 critically ill patients with ARF were randomly assigned to receive CVVHDF with prefilter replacement fluid at an effluent rate of either 35 ml/kg per h (high dosage) or 20 ml/kg per h (standard dosage). The primary study outcome, survival to the earlier of either intensive care unit discharge or 30 d, was 49% in the high-dosage arm and 56% in the standard-dosage arm (odds ratio 0.75; 95% confidence interval 0.43 to 1.32; P = 0.32). Among hospital survivors, 69% of those in the high-dosage arm recovered renal function compared with 80% of those in the standard-dosage arm (P = 0.29); therefore, a difference in patient survival or renal recovery was not detected between patients receiving high-dosage or standard-dosage CVVHDF.
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Affiliation(s)
- Ashita J Tolwani
- Department of Medicine, University of Alabama at Birmingham, Birmingham, Alabama, USA.
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Abstract
Acute renal failure (ARF) with the concomitant need for renal replacement therapy (RRT) is a common complication of critical care medicine that is still associated with high mortality. Different RRT strategies, like intermittent hemodialysis, continuous venovenous hemofiltration, or hybrid forms that combine the advantages of both techniques, are available and will be discussed in this article. Since a general survival benefit has not been demonstrated for either method, it is the task of the nephrologist or intensivist to choose the RRT strategy that is most advantageous for each individual patient. The underlying disease, its severity and stage, the etiology of ARF, the clinical and hemodynamic status of the patient, the resources available, and the different costs of therapy may all influence the choice of the RRT strategy. ARF, with its risk of uremic complications, represents an independent risk factor for outcome in critically ill patients. In addition, the early initiation of RRT with adequate doses is associated with improved survival. Therefore, the "undertreatment" of ARF should be avoided, and higher RRT doses than those in patients with chronic renal insufficiency, independent of whether convective or diffusive methods are used, are indicated in critically ill patients. However, clear guidelines on the dose of RRT and the timing of initiation are still lacking. In particular, it remains unclear whether hemodynamically unstable patients with septic shock benefit from early RRT initiation and the use of increased RRT doses, and whether RRT can lead to a clinically relevant removal of inflammatory mediators.
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Affiliation(s)
- Stefan John
- Department of Nephrology and Hypertension, University of Erlangen-Nuremberg, Krankenhausstrasse 12, 91054 Erlangen, Germany.
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