Continuous Renal Replacement Therapy (CRRT) is the standard of care for management of critically ill patients with acute renal failure. Part of the Pittsburgh Critical Care series, Continuous Renal Replacement Therapy provides concise, evidence-based, bedside guidance about this treatment modality, offering quick reference answers to clinicians' questions about treatments and situations encountered in daily practice. Organized into sections on theory, practice, special situations, and organizational issues, this volume provides a complete view of CRRT theory and practice. Tables summarize and highlight key points, and key studies and trials are included in each chapter. The second edition has been updated to include a new chapter on the use of biomarkers to aid in patient selection and timing, extensive revisions on terminology and nomenclature to match current standards, and the most up-to-date information on newly developed CRRT machines.
The initial observations of dialytic support were brought from the laboratory and confined to patients with reversible acute renal failure. The thought at that time was one of short term maintenance. It was theorized that removal of waste products from the blood, albeit incomplete and inefficient, might allow these patients time to regenerate damaged tubules and regain renal function. After a dis appointing earlier experience in survival, greater sophisti cation and broader practice refined the dialysis skills and reduced mortality. It also became apparent that long periods of support were possible and successful attempts were then made in utilizing this technology in patients with chronic renal failure. These early young patients were a very select group who possessed only renal dysfunction and no other systemic involvement. Nonetheless, they demonstrated a one year survival of only 55-64%. There are presently over 80,000 patients on dialytic support in the United States and over 250,000 patients worldwide dependent on artificial replace ment. Mortality statistics vary but despite a 20-30% systemic disease involvement and a fifth decade average age in the North American experience, the one year survival has risen to apparently 90%.
This book provides a current understanding of Continuous Renal Replacement Therapies (CRRT) techniques with a focus on drug dosing in critically ill children receiving CRRT. Strategies include the role of therapeutic drug monitoring, effect of CRRT on drug pharmacokinetics, variations in the drugs properties, newer kidney injury biomarkers and simple and easy methods for estimating drug clearance. The conclusion of this book features case reports focused on the patients’ symptoms and laboratory data as they present in clinical practice and the type of CRRT modality needed to provide quality, safety, and cost-effectiveness of patient care. Pediatric Continuous Renal Replacement Therapy will expand the clinical knowledge and experience of practicing nephrologists and other professionals involved in the care of children suffering from Acute Kidney Injury (AKI) to improve and sustain their quality of life.
In the past decade, CRRT has moved from a niche therapy within specific specialty centers to the standard of care for management of critically ill patients with acute renal failure. Continuous Renal Replacement Therapy provides concise, evidence-based, to-the-point bedside guidance about this treatment modality, offering quick reference answers to clinicians' questions about treatments and situations encountered in daily practice. Organized into sections on Theory; Pratice; Special Situations; and Organizational Issues, Continuous Renal Replacement Therapy provides a complete view of CRRT theory and practice. Generous tables summarize and highlight key points, and key studies and trials are listed in each chapter.
Abstract: A 73-year-old man was transferred to the emergency department (ED). He was found unconscious in his house along with an empty 200-mL bottle of Basta TM, a herbicide containing 18% glufosinate. He was comatose with a Glasgow Coma Scale score of 3. As his blood pressure dropped to 60/30 mmHg despite fluids and norepinephrine, 20% intravenous fat emulsion product was injected. He experienced repeated cardiopulmonary arrests during his first 4 h in the ED. When the arrests occurred, standard cardiopulmonary resuscitation was performed, and boluses of fat emulsion were given. He was given a total of 1500 mL of 20% fat emulsion. In an attempt to correct the acidosis, continuous renal replacement therapy (CRRT) was started. Within 5 min of starting CRRT, the transmembrane pressure increased sharply and the machine stopped.
Abstract : ABSTRACT: The intensity of continuous renal replacement therapy (CRRT) for acute kidney injury (AKI) has been evaluated, but recent randomized clinical trials have failed to demonstrate a beneficial impact of high intensity on the outcomes. High intensity might cause some detrimental results recognized recently as CRRT trauma. This study was undertaken to evaluate the association of CRRT intensity with mortality in a population of AKI patients treated with lower-intensity CRRT in Japan. A retrospective single-center cohort study enrolled 125 AKI patients treated with CRRT in mixed intensive care units of a university hospital in Japan. Subanalysis was conducted for septic and postsurgical AKI. The median value of the prescribed total effluent rate was 20.1 (interquartile range 15.3–27.1) mL/kg/h. Overall, univariate Cox regression analysis indicated no association of the CRRT intensity with the 60-day in-hospital mortality rate (hazard ratio 1.006, 95% confidence interval [CI] 0.991–1.018, P = 0.343). In subanalysis with the septic AKI patients, multivariate analysis revealed two factors associated independently with the 60-day mortality rate: the Sequential Organ Failure Assessment score at initiation of CRRT (hazard ratio 1.152, 95% CI 1.025–1.301, P = 0.0171) and the CRRT intensity (hazard ratio 1.024, 95% CI 1.004–1.042, P = 0.0195). The CRRT intensity was associated significantly with higher 60-day in-hospital mortality in septic AKI, suggesting that unknown detrimental effects of CRRT with high-intensity CRRT might worsen the outcomes in septic AKI patients.
Abstract: Hypophosphatemia is a common and potentially serious complication occurring during continuous renal replacement therapy (CRRT). Phosphate supplementation is required in the vast majority of patients undergoing CRRT, particularly beyond the first 48 hours. Supplementation can be provided either as a standalone oral or parenteral treatment or as an additive to CRRT solutions. Each approach has advantages and disadvantages, and clinicians must weigh the individual factors most relevant in their practice setting. Currently there are no consensus protocols for phosphate replacement in CRRT, and many centers replete phosphate in response to hypophosphatemia as opposed to pre‐emptively. Repletion protocols have also been challenged in recent years by shortages in injectable phosphate solutions. More recently a commercially available phosphate‐containing CRRT solution was approved in the United States, but there has been limited clinical experience with this product. In this review, we present recommendations for phosphate repletion in CRRT to prevent hypophosphatemia, and describe our experience using phosphate‐containing CRRT solutions.
Abstract: Maintaining fluid balance, pre‐ and post‐MA‐HCT is essential and usually requires frequent administration of diuretics. Hepatic sinusoidal obstructive syndrome is potentially life‐threatening, especially when associated with AKI and MOF. This study describes six patients who developed AKI‐associated SOS and diuretic‐resistant FO who subsequently underwent CRRT using standardized management guidelines for fluid balance post‐HCT. Retrospective chart review was done for HCT patients between September 2011 and October 2013 at a tertiary care children's hospital. Thirty‐four patients underwent MA‐HCT in the study period. Six patients had SOS complicated by diuretic‐resistant FO and underwent CRRT. Defibrotide was used in three patients. Median time on CRRT was 10.5 days. Sixty‐six percent (N = 4 of 6) of patients had full resolution of SOS symptoms with a mortality rate of 34% (N = 2 of 6). Among patients who had full recovery of SOS symptoms, one patient developed AKI, end‐stage renal diseases and underwent kidney transplantation 34‐months post‐HCT. Thus, of six included patients, two died and one developed ESRD with only 50% (N = 3 of 6) good outcome. Use of a standardized, evidence‐based fluid balance protocol and early initiation of CRRT for HCT‐related AKI/SOS was associated with good outcomes.