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Rinaldo Bellomo - One of the best experts on this subject based on the ideXlab platform.
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Renal Replacement Therapy for Septic Acute Kidney Injury
Critical Care Nephrology, 2019Co-Authors: Matthew J. Maiden, Rinaldo BellomoAbstract:Abstract Patients with septic acute kidney injury (AKI) receiving Renal Replacement therapy have mortality rates among the highest of all critical illnesses. Although the incidence of septic AKI is increasing and Renal Replacement therapies are being used more frequently, there remain many uncertainties about how this treatment is best applied. Techniques for Renal Replacement in the critically ill have become refined over the past two decades. Use of these therapies had been guided largely by clinical experience and observational studies. More recently, controlled clinical studies, most with large cohorts of septic AKI patients, are providing greater insights into the appropriate use of Renal Replacement therapies. This chapter outlines issues to consider when applying Renal Replacement to patients with septic AKI. It will include discussion on duration modes (continuous and intermittent), clearance modes (filtration and dialysis), importance of fluid volume control, the amount of clearance (dose), developments in filter composition, and the stage of disease best to commence Renal Replacement (timing).
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Circuit Hemodynamics and Circuit Failure During Continuous Renal Replacement Therapy.
Critical care medicine, 2019Co-Authors: Benjamin Sansom, Shyamala Sriram, Jeffrey J. Presneill, Rinaldo BellomoAbstract:Objectives:To study hemodynamic changes within continuous Renal Replacement therapy circuits and evaluate their relationship with continuous Renal Replacement therapy longevity.Design:Analysis of downloaded variables recorded by continuous Renal Replacement therapy machines during multiple episodes
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Renal Replacement therapy in the ICU: intermittent hemodialysis, sustained low-efficiency dialysis or continuous Renal Replacement therapy?
Current opinion in critical care, 2018Co-Authors: Amanda Y. Wang, Rinaldo BellomoAbstract:Purpose of reviewSevere acute kidney injury in the ICU setting often requires Renal Replacement therapy (RRT). Intermittent hemodialysis (IHD), hybrid forms of RRT such as sustained low-efficiency dialysis (SLED), as well as continuous Renal Replacement therapy (CRRT) are the three common modalities
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Continuous Renal Replacement therapy: recent advances and future research
Nature Reviews Nephrology, 2010Co-Authors: John R. Prowle, Rinaldo BellomoAbstract:Continuous Renal Replacement therapy (CRRT) is the preferred treatment for acute kidney injury (AKI) in intensive care units (ICUs) throughout much of the developed world. Despite its widespread use, however, no formal proof exists that patient outcomes are improved when CRRT is used in preference to intermittent hemodialysis (IHD). In addition, controversy and center-specific practice variation in the clinical application of CRRT continues, owing to a lack of randomized multicenter studies of both CRRT and IHD providing level 1 data to inform clinical practice. Now, however, the publication of results from the Veterans Affairs/National Institutes of Health Acute Renal Failure Trial Network (ATN) study and the Randomized Evaluation of Normal versus Augmented Level Renal Replacement Therapy (Renal) trial have provided an unparalleled quantity of information to guide clinicians. These pivotal trials investigated different intensities of CRRT in the ICU and provided level 1 evidence that effluent flow rates >25 ml/kg per hour do not improve outcomes in patients in the ICU. In this Review, we discuss the background and results of the ATN and Renal trials and the emerging consensus that CRRT is the most appropriate treatment for AKI in vasopressor-dependent patients in the ICU. Finally, we describe the remaining controversies regarding the use of CRRT and the questions that remain to be answered. Although continuous Renal Replacement therapy (CRRT) is widely used for the treatment of acute kidney injury in intensive care units, controversy in the clinical application of this therapy continues. Results of two recently published randomized controlled trials—the ATN study and the Renal trial—have now provided an unparalleled quantity of information to guide clinicians. Here, Prowle and Bellomo discuss the results of these trials, explain the controversies that still exist regarding the use of CRRT, and describe the questions that remain to be answered. Continuous Renal Replacement therapy (CRRT) is now the leading form of Renal Replacement therapy for acute kidney injury (AKI) in intensive care units (ICUs) worldwide Practice variation in the application of CRRT remains considerable owing to the absence of clear evidence-based guidelines Two large, multicenter, randomized controlled trials have now established that increasing the dose of CRRT above an effluent flow rate of 25 ml/kg per hour is not beneficial CRRT is now widely accepted as the most appropriate therapy for vasopressor-dependent patients who require Renal Replacement therapy for AKI in the ICU A number of aspects of CRRT require further research, particularly the optimal threshold and timing of CRRT Factors such as local experience and cost will probably continue to determine choice of therapy in different regions
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discontinuation of continuous Renal Replacement therapy a post hoc analysis of a prospective multicenter observational study
Critical Care Medicine, 2009Co-Authors: Shigehiko Uchino, Rinaldo Bellomo, Etienne Macedo, Miet Schetz, Catherine S. C. Bouman, Hiroshi Morimatsu, Stanislo Morgera, Ian K S Tan, Noel Gibney, Ashita TolwaniAbstract:Objectives: To describe current practice for the discontinuation of continuous Renal Replacement therapy in a multinational setting and to identify variables associated with successful discontinuation. The approach to discontinue continuous Renal Replacement therapy may affect patient outcomes. However, there is lack of information on how and under what conditions continuous Renal Replacement therapy is discontinued. Design: Post hoc analysis of a prospective observational study. Setting: Fifty-four intensive care units in 23 countries. Patients: Five hundred twenty-nine patients (52.6%) who survived initial therapy among 1006 patients treated with continuous Renal Replacement therapy. Interventions: None. Measurements and Main Results: Three hundred thirteen patients were removed successfully from continuous Renal Replacement therapy and did not require any Renal Replacement therapy for at least 7 days and were classified as the “success” group and the rest (216 patients) were classified as the “repeat-RRT” (Renal Replacement therapy) group. Patients in the “success” group had lower hospital mortality (28.5% vs. 42.7%, p < .0001) compared with patients in the “repeat-RRT” group. They also had lower creatinine and urea concentrations and a higher urine output at the time of stopping continuous Renal Replacement therapy. Multivariate logistic regression analysis for successful discontinuation of continuous Renal Replacement therapy identified urine output (during the 24 hrs before stopping continuous Renal Replacement therapy: odds ratio, 1.078 per 100 mL/day increase) and creatinine (odds ratio, 0.996 per mol/L increase) as significant predictors of successful cessation. The area under the receiver operating characteristic curve to predict successful discontinuation of continuous Renal Replacement therapy was 0.808 for urine output and 0.635 for creatinine. The predictive ability of urine output was negatively affected by the use of diuretics (area under the receiver operating characteristic curve, 0.671 with diuretics and 0.845 without diuretics). Conclusions: We report on the current practice of discontinuing continuous Renal Replacement therapy in a multinational setting. Urine output at the time of initial cessation of continuous Renal Replacement therapy was the most important predictor of successful discontinuation, especially if occurring without the administration of diuretics. (Crit Care Med 2009; 37:2576‐2582)
Stuart L. Goldstein - One of the best experts on this subject based on the ideXlab platform.
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Renal Replacement Therapy in Neonates
Clinics in perinatology, 2014Co-Authors: Ahmad Kaddourah, Stuart L. GoldsteinAbstract:The incidence of acute kidney injury (AKI) has steadily increased in the last decade in neonates and infants. Despite the extensive proposed pharmacologic approaches to treat or prevent AKI, Renal Replacement therapy is the only available therapeutic approach to manage the consequences of significant AKI and maintain electrolyte homeostasis and fluid balance in infants with AKI. The objective of this article is to summarize the different approaches and modalities of Renal Replacement therapy in neonatal intensive care units.
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Renal Replacement therapy and the kidney: minimizing the impact of Renal Replacement therapy on recovery of acute Renal failure.
Current opinion in critical care, 2005Co-Authors: Paul M. Palevsky, Ian T. Baldwin, Andrew Davenport, Stuart L. Goldstein, Emil P. PaganiniAbstract:Purpose of review Although Renal Replacement therapy is the mainstay of supportive care in patients with severe acute Renal failure, its performance can have untoward effects that contribute to the prolongation of Renal failure or impede the ultimate recovery of Renal function. In this review, we categorize the major complications associated with Renal Replacement therapy and assess their impact on recovery of Renal function. Recent findings The major mechanisms by which Renal Replacement therapy is postulated to delay Renal recovery include treatment-associated hemodynamic instability, vascular catheter-related bacteremia and sepsis, and cytokine activation by bioincompatible membranes. Clinical data regarding the role of dialysis catheter infections in delay of Renal recovery are lacking. The data regarding the role of membrane biocompatibility and the modality and dose of Renal Replacement therapy are limited and conflicting. Summary Clinical recommendations must be limited to the broad admonishment that complications during Renal Replacement therapy, including hemodynamic instability and catheter-related bacteremia, be minimized by using best clinical practices, while recognizing that the impact of specific practices on recovery of Renal function have not been evaluated. The data do not support recommendations regarding utilization of specific membranes or the modality or dose of Renal Replacement therapy on the basis of their impact on recovery of Renal function.
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Overview of pediatric Renal Replacement therapy in acute Renal failure.
Artificial organs, 2003Co-Authors: Stuart L. GoldsteinAbstract:The disease spectrum leading to pediatric Renal Replacement therapy (RRT) provision has broadened over the last decade. In the 1980s, intrinsic Renal disease and burns constituted the most common pediatric acute Renal failure etiologies. More recent data demonstrate that pediatric acute Renal failure (ARF) most often results from complications of other systemic diseases, resulting from advancements in congenital heart surgery, neonatal care, and bone marrow and solid organ transplantation. In addition, RRT modality preferences to treat critically ill children have shifted from peritoneal dialysis to continuous Renal Replacement therapy (CRRT) as a result of improvements in CRRT technologies. Currently, multicenter prospective outcome studies for critically ill children with ARF are sorely lacking. The aims of this article are to review the pediatric specific causes necessitating Renal Replacement therapy provision, with an emphasis on emerging practice patterns with respect to modality and the timing of treatment, and to focus upon the application of the different Renal Replacement therapy modalities and assessment of the outcome of children with ARF who receive Renal Replacement therapy.
Heleen M. Oudemans-van Straaten - One of the best experts on this subject based on the ideXlab platform.
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Primum non nocere, safety of continuous Renal Replacement therapy.
Current Opinion in Critical Care, 2007Co-Authors: Heleen M. Oudemans-van StraatenAbstract:PURPOSE OF REVIEW: To highlight selected adverse effects of continuous Renal Replacement therapy and to suggest measures for reducing harm. RECENT FINDINGS: Adverse effects of continuous Renal Replacement therapy are related to bioincompatibility, bleeding, metabolic consequences, loss of heat, vascular access and human error. Bioincompatibility initiates coagulation and inflammation. Use of membranes with high pore size permits direct removal of the locally formed inflammatory mediators. Regional anticoagulation with citrate reduces the risk of bleeding and abolishes polymorphonuclear and platelet degranulation in the filter. Continuous Renal Replacement therapy is associated with increased losses of amino acids and the water-soluble vitamins carnitine and selenium. Compared to bicarbonate, lactate-buffered fluids may increase energy needs and glucose intolerance. Patients on continuous Renal Replacement therapy may lose heat. SUMMARY: Several measures can be considered to improve safety of continuous Renal Replacement therapy. Among these are the use of membranes with high pore size, implementation of citrate to reduce bleeding and bioincompatibility, supplementation of water-soluble vitamins and selenium to increase antioxidant defense, use of bicarbonate-buffered solutions in the most critically ill, and prevention of loss of heat. Last but not least, improvement of safety needs continuous training of staff for better understanding of the method.
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Primum non nocere, safety of continuous Renal Replacement therapy.
Current opinion in critical care, 2007Co-Authors: Heleen M. Oudemans-van StraatenAbstract:Purpose of reviewTo highlight selected adverse effects of continuous Renal Replacement therapy and to suggest measures for reducing harm.Recent findingsAdverse effects of continuous Renal Replacement therapy are related to bioincompatibility, bleeding, metabolic consequences, loss of heat, vascular
Claudio Ronco - One of the best experts on this subject based on the ideXlab platform.
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Renal Replacement Therapy
F1000Research, 2016Co-Authors: Zaccaria Ricci, Stefano Romagnoli, Claudio RoncoAbstract:During the last few years, due to medical and surgical evolution, patients with increasingly severe diseases causing multiorgan dysfunction are frequently admitted to intensive care units. Therapeutic options, when organ failure occurs, are frequently nonspecific and mostly directed towards supporting vital function. In these scenarios, the kidneys are almost always involved and, therefore, Renal Replacement therapies have become a common routine practice in critically ill patients with acute kidney injury. Recent technological improvement has led to the production of safe, versatile and efficient dialysis machines. In addition, emerging evidence may allow better individualization of treatment with tailored prescription depending on the patients’ clinical picture (e.g. sepsis, fluid overload, pediatric). The aim of the present review is to give a general overview of current practice in Renal Replacement therapies for critically ill patients. The main clinical aspects, including dose prescription, modality of dialysis delivery, anticoagulation strategies and timing will be addressed. In addition, some technical issues on physical principles governing blood purification, filters characteristics, and vascular access, will be covered. Finally, a section on current standard nomenclature of Renal Replacement therapy is devoted to clarify the “Tower of Babel” of critical care nephrology.
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Renal Replacement Therapy
Critical Care Clinics, 2015Co-Authors: Gianluca Villa, Zaccaria Ricci, Claudio RoncoAbstract:Endogenous toxins accumulate in blood as a result of many biochemical processes.1 If their concentration exceeds certain levels, they cause illness. Some toxins are volatile (e.g., CO2, ketones) and can be excreted by the lungs through ventilation; others are lipophilic (e.g., bile acids, bilirubin) and can be excreted by the liver via the biliary system; yet others are water soluble and nonvolatile and are excreted by the kidneys.2 When acute kidney injury (AKI) occurs, these water-soluble substances (potassium, phosphate, urea, creatinine) and endogenous toxins (methylguanidine, guanidinosuccinic acid, hippuric acid, uric acid, phenols, beta-2 microglobulin, purines, myo-inositol, etc.), which are normally excreted by the kidney, accumulate in blood. If accumulation progresses, AKI becomes severe; and if their removal is not addressed by either Renal recovery or the initiation of artificial Renal Replacement therapy, the patient dies from uncontrolled hyperkalemia or uremia. Unfortunately, AKI requiring Renal Replacement therapy (RRT) is relatively common in critically ill patients treated in the intensive care unit (ICU) and involves close to 5% of all admissions.3 When a decision is made that artificial Renal Replacement therapy is needed, the physician has a variety of techniques at his/her disposal: intermittent hemodialysis (IHD), continuous Renal Replacement therapy (CCRT), slow extended daily dialysis (SLEDD), and peritoneal dialysis, each with its technical variations. All of these techniques rely on the principle that unwanted solutes and water can be removed through a semipermeable membrane-based separating process. The principles of such process have been extensively studied and described.4,5
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Continuous Renal Replacement Therapy (CRRT)
Studies in Computational Intelligence, 2013Co-Authors: Jorge Cerdá, Ashita Tolwani, Shamik Shah, Claudio RoncoAbstract:This chapter will summarize current knowledge in Renal Replacement technologies in the treatment of critically ill patients with acute kidney injury. The mechanics of different treatment modalities with emphasis on continuous Renal Replacement therapies will be described, as well as the application of such technologies in the management of fluid overload and metabolic abnormalities. Appropriate composition of dialysate and Replacement fluids, use of anticoagulation, choice of vascular access, and potential complications in the use of such technologies will be discussed. Finally, the chapter will compare the main features of the different currently available CRRT machines.
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Renal Replacement therapies: physiological review.
Intensive Care Medicine, 2008Co-Authors: Claudio Ronco, Zaccaria RicciAbstract:Introduction A physiological review on Renal Replacement therapies (RRT) is a challenging task: there is nothing "physiologic" about RRT, since the most accurate, safe and perfectly delivered extracorporeal therapy would still be far from "physiologically" replacing the function of the native kidney.
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Dose and efficiency of Renal Replacement therapy: continuous Renal Replacement therapy versus intermittent hemodialysis versus slow extended daily dialysis.
Critical care medicine, 2008Co-Authors: Zaccaria Ricci, Claudio RoncoAbstract:Acute kidney injury represents an independent risk of death in the intensive care unit and significantly contributes to in-hospital mortality. The only accepted treatment of severe acute kidney injury so far is Renal Replacement therapy, which is not a causative therapy but rather a life-support treatment. Renal Replacement therapy can be performed by several different techniques: intermittent hemodialysis, slow extended daily dialysis, peritoneal dialysis, or continuous Renal Replacement therapy. There is controversy about which technique should be used, which dosage should be selected for each therapy, and whether the technique and/or the dose of Renal Replacement therapy may impact survival in critically ill patients. After a careful review of the recent literature, definitive conclusions cannot be drawn: Trials are in most cases underpowered and conducted over many years, in which significant changes in the practice of acute dialytic techniques have taken place. Other studies have described therapeutic modalities requiring a high level of specific expertise in the field and generally not easily reproducible in the routine practice. While practitioners are waiting for the ultimate trial to be published, we think it is worth reporting some broad concepts and few suggestions for Renal Replacement therapy prescription derived from current evidence and from the available experience.
Zaccaria Ricci - One of the best experts on this subject based on the ideXlab platform.
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Renal Replacement Therapy
F1000Research, 2016Co-Authors: Zaccaria Ricci, Stefano Romagnoli, Claudio RoncoAbstract:During the last few years, due to medical and surgical evolution, patients with increasingly severe diseases causing multiorgan dysfunction are frequently admitted to intensive care units. Therapeutic options, when organ failure occurs, are frequently nonspecific and mostly directed towards supporting vital function. In these scenarios, the kidneys are almost always involved and, therefore, Renal Replacement therapies have become a common routine practice in critically ill patients with acute kidney injury. Recent technological improvement has led to the production of safe, versatile and efficient dialysis machines. In addition, emerging evidence may allow better individualization of treatment with tailored prescription depending on the patients’ clinical picture (e.g. sepsis, fluid overload, pediatric). The aim of the present review is to give a general overview of current practice in Renal Replacement therapies for critically ill patients. The main clinical aspects, including dose prescription, modality of dialysis delivery, anticoagulation strategies and timing will be addressed. In addition, some technical issues on physical principles governing blood purification, filters characteristics, and vascular access, will be covered. Finally, a section on current standard nomenclature of Renal Replacement therapy is devoted to clarify the “Tower of Babel” of critical care nephrology.
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Renal Replacement Therapy
Critical Care Clinics, 2015Co-Authors: Gianluca Villa, Zaccaria Ricci, Claudio RoncoAbstract:Endogenous toxins accumulate in blood as a result of many biochemical processes.1 If their concentration exceeds certain levels, they cause illness. Some toxins are volatile (e.g., CO2, ketones) and can be excreted by the lungs through ventilation; others are lipophilic (e.g., bile acids, bilirubin) and can be excreted by the liver via the biliary system; yet others are water soluble and nonvolatile and are excreted by the kidneys.2 When acute kidney injury (AKI) occurs, these water-soluble substances (potassium, phosphate, urea, creatinine) and endogenous toxins (methylguanidine, guanidinosuccinic acid, hippuric acid, uric acid, phenols, beta-2 microglobulin, purines, myo-inositol, etc.), which are normally excreted by the kidney, accumulate in blood. If accumulation progresses, AKI becomes severe; and if their removal is not addressed by either Renal recovery or the initiation of artificial Renal Replacement therapy, the patient dies from uncontrolled hyperkalemia or uremia. Unfortunately, AKI requiring Renal Replacement therapy (RRT) is relatively common in critically ill patients treated in the intensive care unit (ICU) and involves close to 5% of all admissions.3 When a decision is made that artificial Renal Replacement therapy is needed, the physician has a variety of techniques at his/her disposal: intermittent hemodialysis (IHD), continuous Renal Replacement therapy (CCRT), slow extended daily dialysis (SLEDD), and peritoneal dialysis, each with its technical variations. All of these techniques rely on the principle that unwanted solutes and water can be removed through a semipermeable membrane-based separating process. The principles of such process have been extensively studied and described.4,5
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Renal Replacement therapies: physiological review.
Intensive Care Medicine, 2008Co-Authors: Claudio Ronco, Zaccaria RicciAbstract:Introduction A physiological review on Renal Replacement therapies (RRT) is a challenging task: there is nothing "physiologic" about RRT, since the most accurate, safe and perfectly delivered extracorporeal therapy would still be far from "physiologically" replacing the function of the native kidney.
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Dose and efficiency of Renal Replacement therapy: continuous Renal Replacement therapy versus intermittent hemodialysis versus slow extended daily dialysis.
Critical care medicine, 2008Co-Authors: Zaccaria Ricci, Claudio RoncoAbstract:Acute kidney injury represents an independent risk of death in the intensive care unit and significantly contributes to in-hospital mortality. The only accepted treatment of severe acute kidney injury so far is Renal Replacement therapy, which is not a causative therapy but rather a life-support treatment. Renal Replacement therapy can be performed by several different techniques: intermittent hemodialysis, slow extended daily dialysis, peritoneal dialysis, or continuous Renal Replacement therapy. There is controversy about which technique should be used, which dosage should be selected for each therapy, and whether the technique and/or the dose of Renal Replacement therapy may impact survival in critically ill patients. After a careful review of the recent literature, definitive conclusions cannot be drawn: Trials are in most cases underpowered and conducted over many years, in which significant changes in the practice of acute dialytic techniques have taken place. Other studies have described therapeutic modalities requiring a high level of specific expertise in the field and generally not easily reproducible in the routine practice. While practitioners are waiting for the ultimate trial to be published, we think it is worth reporting some broad concepts and few suggestions for Renal Replacement therapy prescription derived from current evidence and from the available experience.
