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.
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- 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
- SOCIETY GUIDELINE LINKS
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS