Continuous renal replacement therapy in acute kidney injury (acute renal failure)
- Thomas A Golper, MD
Thomas A Golper, MD
- Section Editor — Dialysis
- Professor of Medicine
- Vanderbilt University Medical Center
Dialysis may be required in patients with severe acute kidney injury (AKI, acute renal failure [ARF]). Most patients have been treated with hemodialysis, with the dialysis prescription varying in part with the presence or absence of hypercatabolism. An alternative approach is the use of continuous renal replacement therapy (CRRT).
POSSIBLE DIFFERENCES BETWEEN INTERMITTENT HEMODIALYSIS AND CRRT
Hemodynamic stability — Daily or every other day conventional hemodialysis is the standard dialytic regimen for the hemodynamically stable patient with severe ARF. However, hypotension, due in part to rapid fluid and solute removal, is one of the most common complications with this technique, making it less desirable in the patient who is hypotensive or hemodynamically unstable. In contrast, the rate of fluid and solute removal is slow, and hypotension is less common with the CRRTs, such as continuous arteriovenous hemofiltration or hemodialysis (CAVH or CAVHD) [1-4]. A review of the characteristics of the different types of CRRT is available elsewhere. (See "Continuous renal replacement therapies: Overview".)
CRRT has the additional advantage of effectively removing excess fluid in hypotensive patients, while hemodialysis is frequently limited by a further reduction in blood pressure in this setting.
The relative hemodynamic instability associated with hemodialysis is related to several factors, which are discussed in detail elsewhere. (See "Renal replacement therapy (dialysis) in acute kidney injury (acute renal failure): Metabolic and hemodynamic considerations".)
●The rapid rate of solute removal results in an abrupt fall in plasma osmolality that induces further extracellular volume depletion by promoting osmotic water movement into the cells (figure 1). The reduction in plasma osmolality itself may contribute to the development of hypotension.
- Golper TA. Indications, technical considerations, and strategies for renal replacement therapy in the intensive care unit. J Intensive Care Med 1992; 7:310.
- Forni LG, Hilton PJ. Continuous hemofiltration in the treatment of acute renal failure. N Engl J Med 1997; 336:1303.
- Ronco C. Continuous renal replacement therapies for the treatment of acute renal failure in intensive care patients. Clin Nephrol 1993; 40:187.
- Manns M, Sigler MH, Teehan BP. Continuous renal replacement therapies: an update. Am J Kidney Dis 1998; 32:185.
- Ziegler EJ, Fisher CJ Jr, Sprung CL, et al. Treatment of gram-negative bacteremia and septic shock with HA-1A human monoclonal antibody against endotoxin. A randomized, double-blind, placebo-controlled trial. The HA-1A Sepsis Study Group. N Engl J Med 1991; 324:429.
- Moldawer LL. Interleukin-1, TNF alpha and their naturally occurring antagonists in sepsis. Blood Purif 1993; 11:128.
- Stein B, Pfenninger E, Grünert A, et al. Influence of continuous haemofiltration on haemodynamics and central blood volume in experimental endotoxic shock. Intensive Care Med 1990; 16:494.
- Gomez A, Wang R, Unruh H, et al. hemofiltration reverses left ventricular dysfunction during sepsis in dogs. Anesthesiology 1990; 73:671.
- Hoffmann JN, Hartl WH, Deppisch R, et al. Hemofiltration in human sepsis: evidence for elimination of immunomodulatory substances. Kidney Int 1995; 48:1563.
- Barzilay E, Kessler D, Berlot G, et al. Use of extracorporeal supportive techniques as additional treatment for septic-induced multiple organ failure patients. Crit Care Med 1989; 17:634.
- Storck M, Hartl WH, Zimmerer E, Inthorn D. Comparison of pump-driven and spontaneous continuous haemofiltration in postoperative acute renal failure. Lancet 1991; 337:452.
- Piccinni P, Dan M, Barbacini S, et al. Early isovolaemic haemofiltration in oliguric patients with septic shock. Intensive Care Med 2006; 32:80.
- Cole L, Bellomo R, Journois D, et al. High-volume haemofiltration in human septic shock. Intensive Care Med 2001; 27:978.
- Kvist T, Reit C. Results of endodontic retreatment: a randomized clinical study comparing surgical and nonsurgical procedures. J Endod 1999; 25:814.
- Cole L, Bellomo R, Silvester W, Reeves JH. A prospective, multicenter study of the epidemiology, management, and outcome of severe acute renal failure in a "closed" ICU system. Am J Respir Crit Care Med 2000; 162:191.
- Honore PM, Jamez J, Wauthier M, et al. Prospective evaluation of short-term, high-volume isovolemic hemofiltration on the hemodynamic course and outcome in patients with intractable circulatory failure resulting from septic shock. Crit Care Med 2000; 28:3581.
- Boussekey N, Chiche A, Faure K, et al. A pilot randomized study comparing high and low volume hemofiltration on vasopressor use in septic shock. Intensive Care Med 2008; 34:1646.
- Payen D, Mateo J, Cavaillon JM, et al. Impact of continuous venovenous hemofiltration on organ failure during the early phase of severe sepsis: a randomized controlled trial. Crit Care Med 2009; 37:803.
- Wu VC, Wang CH, Wang WJ, et al. Sustained low-efficiency dialysis versus continuous veno-venous hemofiltration for postsurgical acute renal failure. Am J Surg 2010; 199:466.
- Kaplan AA, Longnecker RE, Folkert VW. Suction-assisted continuous arteriovenous hemofiltration. Trans Am Soc Artif Intern Organs 1983; 29:408.
- Olbricht CJ, Haubitz M, Häbel U, et al. Continuous arteriovenous hemofiltration: in vivo functional characteristics and its dependence on vascular access and filter design. Nephron 1990; 55:49.
- Kaplan AA. Predilution versus postdilution for continuous arteriovenous hemofiltration. Trans Am Soc Artif Intern Organs 1985; 31:28.
- Kaplan AA. Clinical trials with predilution and vacuum suction: enhancing the efficiency of the CAVH treatment. ASAIO Trans 1986; 32:49.
- Golper TA. Continuous arteriovenous hemofiltration in acute renal failure. Am J Kidney Dis 1985; 6:373.
- Macias WL, Mueller BA, Scarim SK, et al. Continuous venovenous hemofiltration: an alternative to continuous arteriovenous hemofiltration and hemodiafiltration in acute renal failure. Am J Kidney Dis 1991; 18:451.
- Ronco C, Bellomo R, Homel P, et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 2000; 356:26.
- Sigler MH, Teehan BP. Solute transport in continuous hemodialysis: a new treatment for acute renal failure. Kidney Int 1987; 32:562.
- van Geelen JA, Vincent HH, Schalekamp MA. Continuous arteriovenous haemofiltration and haemodiafiltration in acute renal failure. Nephrol Dial Transplant 1988; 3:181.
- Hu KT, Yeun JY, Craig M, et al. Extended daily dialysis: An alternative to continuous venovenous hemofiltration in the intensive care unit. Blood Purif 1999; 17:28.
- Marshall MR, Golper TA, Shaver MJ, et al. Sustained low-efficiency dialysis for critically ill patients requiring renal replacement therapy. Kidney Int 2001; 60:777.
- POSSIBLE DIFFERENCES BETWEEN INTERMITTENT HEMODIALYSIS AND CRRT
- Hemodynamic stability
- Solute removal
- Removal of immunomodulatory substances in sepsis
- Effect on mortality
- USE OF CONTINUOUS RENAL REPLACEMENT THERAPY AND CHOICE OF DIALYSIS MODALITY
- Choice of continuous modality or intermittent hemodialysis
- Slow continuous ultrafiltration
- Continuous arteriovenous hemofiltration
- Continuous venovenous hemofiltration
- Continuous arteriovenous hemodialysis
- Continuous venovenous hemodialysis
- Peritoneal dialysis
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS