Continuous renal replacement therapy (CRRT) is commonly used to provide renal support for critically ill patients with acute kidney injury, particularly patients who are hemodynamically unstable. A ...variety of techniques that differ in their mode of solute clearance may be used, including continuous venovenous hemofiltration with predominantly convective solute clearance, continuous venovenous hemodialysis with predominantly diffusive solute clearance, and continuous venovenous hemodiafiltration, which combines both dialysis and hemofiltration. The present article compares CRRT with other modalities of renal support and reviews indications for initiation of renal replacement therapy, as well as dosing and technical aspects in the management of CRRT.
The selection of modality of kidney replacement therapy has been debated for decades. Although the KDIGO Clinical Practice Guidelines for Acute Kidney Injury consider intermittent hemodialysis and ...continuous kidney replacement therapy (CKRT) to be complementary therapies, with a recommendation to preferably use CKRT in hemodynamically unstable patients, there is a vocal cadre of practitioners and investigators who argue that CKRT is the only modality that should be used to support critically ill patients with acute kidney injury, relying on observational data to argue that intermittent hemodialysis is associated with impaired recovery of kidney function. In this issue of CJASN we have provided a virtual debate allowing advocates for and against the use of intermittent hemodialysis to make their best cases. In the end, their arguments converge, with a call for more data and a pragmatic, patient-focused approach to the delivery of KRT to critically ill patients with acute kidney injury.
In response to the recently released 2012 KDIGO (Kidney Disease: Improving Global Outcomes) clinical practice guideline for acute kidney injury (AKI), the National Kidney Foundation organized a group ...of US experts in adult and pediatric AKI and critical care nephrology to review the recommendations and comment on their relevancy in the context of current US clinical practice and concerns. The first portion of the KDIGO guideline attempts to harmonize earlier consensus definitions and staging criteria for AKI. While the expert panel thought that the KDIGO definition and staging criteria are appropriate for defining the epidemiology of AKI and in the design of clinical trials, the panel concluded that there is insufficient evidence to support their widespread application to clinical care in the United States. The panel generally concurred with the remainder of the KDIGO guidelines that are focused on the prevention and pharmacologic and dialytic management of AKI, although noting the dearth of clinical trial evidence to provide strong evidence-based recommendations and the continued absence of effective therapies beyond hemodynamic optimization and avoidance of nephrotoxins for the prevention and treatment of AKI.
IMPORTANCE: Polymyxin B hemoperfusion reduces blood endotoxin levels in sepsis. Endotoxin activity can be measured in blood with a rapid assay. Treating patients with septic shock and elevated ...endotoxin activity using polymyxin B hemoperfusion may improve clinical outcomes. OBJECTIVE: To test whether adding polymyxin B hemoperfusion to conventional medical therapy improves survival compared with conventional therapy alone among patients with septic shock and high endotoxin activity. DESIGN, SETTING, AND PARTICIPANTS: Multicenter, randomized clinical trial involving 450 adult critically ill patients with septic shock and an endotoxin activity assay level of 0.60 or higher enrolled between September 2010 and June 2016 at 55 tertiary hospitals in North America. Last follow-up was June 2017. INTERVENTIONS: Two polymyxin B hemoperfusion treatments (90-120 minutes) plus standard therapy completed within 24 hours of enrollment (n = 224 patients) or sham hemoperfusion plus standard therapy (n = 226 patients). MAIN OUTCOMES AND MEASURES: The primary outcome was mortality at 28 days among all patients randomized (all participants) and among patients randomized with a multiple organ dysfunction score (MODS) of more than 9. RESULTS: Among 450 eligible enrolled patients (mean age, 59.8 years; 177 39.3% women; mean APACHE II score 29.4 range, 0-71 with higher scores indicating greater severity), 449 (99.8%) completed the study. Polymyxin B hemoperfusion was not associated with a significant difference in mortality at 28 days among all participants (treatment group, 84 of 223 37.7% vs sham group 78 of 226 34.5%; risk difference RD, 3.2%; 95% CI, −5.7% to 12.0%; relative risk RR, 1.09; 95% CI, 0.85-1.39; P = .49) or in the population with a MODS of more than 9 (treatment group, 65 of 146 44.5% vs sham, 65 of 148 43.9%; RD, 0.6%; 95% CI, −10.8% to 11.9%; RR, 1.01; 95% CI, 0.78-1.31; P = .92). Overall, 264 serious adverse events were reported (65.1% treatment group vs 57.3% sham group). The most frequent serious adverse events were worsening of sepsis (10.8% treatment group vs 9.1% sham group) and worsening of septic shock (6.6% treatment group vs 7.7% sham group). CONCLUSIONS AND RELEVANCE: Among patients with septic shock and high endotoxin activity, polymyxin B hemoperfusion treatment plus conventional medical therapy compared with sham treatment plus conventional medical therapy did not reduce mortality at 28 days. TRIAL REGISTRATION: ClinicalTrials.gov Identifier: NCT01046669
Among high-risk patients undergoing angiography, there was no benefit of intravenous sodium bicarbonate over sodium chloride or of oral acetylcysteine over placebo for the prevention of death, ...dialysis, or contrast-associated acute kidney injury.
Consensus definitions have been reached for both acute kidney injury (AKI) and chronic kidney disease (CKD) and these definitions are now routinely used in research and clinical practice. The KDIGO ...guideline defines AKI as an abrupt decrease in kidney function occurring over 7 days or less, whereas CKD is defined by the persistence of kidney disease for a period of >90 days. AKI and CKD are increasingly recognized as related entities and in some instances probably represent a continuum of the disease process. For patients in whom pathophysiologic processes are ongoing, the term acute kidney disease (AKD) has been proposed to define the course of disease after AKI; however, definitions of AKD and strategies for the management of patients with AKD are not currently available. In this consensus statement, the Acute Disease Quality Initiative (ADQI) proposes definitions, staging criteria for AKD, and strategies for the management of affected patients. We also make recommendations for areas of future research, which aim to improve understanding of the underlying processes and improve outcomes for patients with AKD.
In this study, patients with type 2 diabetes, albuminuria, and mild-to-moderate renal dysfunction received losartan followed by lisinopril or placebo. The study was stopped early because of increased ...risks of hyperkalemia and acute kidney injury with combination therapy.
Diabetic nephropathy is the leading cause of end-stage renal disease (ESRD) in the United States.
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Persons with diabetes and proteinuria are at high risk for progression to ESRD.
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Blockade of the renin–angiotensin system decreases the progression of proteinuric kidney disease,
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and the degree of reduction in proteinuria correlates with the extent to which the decrease in the glomerular filtration rate (GFR) is slowed.
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Given these observations, it has been hypothesized that interventions that further lower proteinuria will further reduce the risk of progression.
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Combination therapy with an angiotensin-converting–enzyme (ACE) inhibitor and an angiotensin II–receptor blocker (ARB) results in . . .
Acute kidney injury can be accompanied by life-threatening electrolyte and metabolic abnormalities. Kidney-replacement therapy may be urgently needed to prevent death from uremia. This review ...considers treatment approaches, indications, and intensity in critically ill patients with AKI.
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