Continuous Renal Replacement Therapies: A Brief Primer for the Neurointensivist
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REVIEW ARTICLE
Continuous Renal Replacement Therapies: A Brief Primer for the Neurointensivist Pritesh Patel • Veena Nandwani • Paul J. McCarthy Steven A. Conrad • L. Keith Scott
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Published online: 12 June 2010 Ó Springer Science+Business Media, LLC 2010
Abstract Continuous renal replacement therapy (CRRT) is a renal replacement modality that is often used in the ICU setting, including the neuro-ICU. This form of renal replacement therapy has been used classically for acute renal failure in patients with hemodynamic compromise, but is gaining acceptance as a method to control vascular and extra-vascular volume and mediate cytokines in nonrenal diseases. Although these uses are briefly discussed, this review concentrates on the different forms of continuous renal replacement, mainly focusing on the technology of convective versus diffusive modalities and briefly on filter technology. There is also discussion on the various anticoagulation regimes used in CRRT including data on performing CRRT without anticoagulation. This review is not meant to be a discussion on the pros and cons of CRRT versus intermittent dialysis, but rather a primer on the technology of CRRT and how this therapy may affect general care of the ICU patient. Keywords CRRT CVVH CVVHDF Diffusive clearance Convective clearance
P. Patel V. Nandwani P. J. McCarthy S. A. Conrad L. Keith Scott (&) Department of Medicine, Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport, LA 71130, USA e-mail: [email protected] P. J. McCarthy S. A. Conrad L. Keith Scott Department of Neurosurgery, Louisiana State University Health Sciences Center, 1501 Kings Hwy, Shreveport, LA 71130, USA
Introduction Acute renal failure (ARF) related to critical illness is a significant contributor to poor outcome regardless of the primary diagnoses or condition that warranted ICU care [1–4]. Intermittent or continuous renal replacement therapy (CRRT) remains the cornerstone in treating ARF and/or refractory volume overload in the ICU and has been for over 30 years. There is ongoing debate as to the type of renal replacement therapy (RRT) that is superior in the intensive care setting. Debates range from who should manage the therapy, what the goals of the therapy should be to what type of therapy are best—intermittent or continuous. Even timing of the initiation of RRT is debated and remains an unsettled issue [5]. The CRRT or intermittent hemodialysis (IHD) debate generates strong biases and opinions an in spite of recent studies to suggest equipoise, the controversy remains [6, 7]. Many institutions offer both therapies and have different criteria in choosing which to use. This is a discussion of CRRT technology and not a position paper advocating one therapy over another. CRRT is a form of RRT that is used continuously to treat not only ARF, but has also been utilized to treat a variety of ICU conditions without ARF such as shock and pancreatitis [8, 9]. CRRT incorporates several modes of RRT utilizing different mechanisms of clea
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