Management of Acute Kidney Problems (eBook)

Preface 6
Contents 8
Contributors 25
Definition and Classificationof Acute Kidney Failure 34
Definition and Classification of Acute Kidney Injury 35
Core Messages 35
1.1.1 Introduction 35
1.1.2 What Is Acute Kidney Injury? Current Controversies 35
1.1.3 Renal “Failure” or Renal “Success” 36
1.1.4 Oliguria and Anuria 36
1.1.5 Prerenal Azotemia and Acute Tubular Necrosis 36
1.1.6 Limitations of Biomarkers 37
1.1.7 Renal Failure Defined by RIFLE Criteria 37
1.1.8 The Concept of Acute Kidney Injury: A Paradigm Shift 38
1.1.9 Validation Studies Using RIFLE 38
1.1.10 Conceptual Development and Future Directions 40
1.1.11 Conclusions 40
References 40
Overview of Pathophysiology,Etiology and Epidemiology 42
Mechanisms of Acute Kidney Injury and Repair 43
Core Messages 43
2.1.1 Introduction 43
2.1.2 Injury 44
2.1.3 Inflammation 45
2.1.4 Paracrine Effects of Bone Marrow–Derived Stem Cells 47
2.1.5 Other Mechanisms to Limit or Stop Inflammation 47
2.1.6 Repair 48
2.1.7 Conclusions 48
References 49
Uremic Toxins 51
Core Messages 51
2.2.1 Introduction 51
2.2.2 Interfering Factors Due to Renal Replacement Therapy 51
2.2.3 Biochemical Alterations 52
2.2.3.1 Enzymatic Processes 52
2.2.3.2 Drug Protein Binding 53
2.2.4 Factors Responsible for the Uremic Syndrome 53
2.2.5 Major Low-Molecular-Weight Uremic Retention Products 54
2.2.5.1 Advanced Glycosylation End Products 54
2.2.5.2 Creatinine 55
2.2.5.3 Dimethylarginine 55
2.2.5.4 Guanidines 55
2.2.5.5 Hippuric Acid 56
2.2.5.6 Homocysteine 56
2.2.5.7 Indoxyl Sulphate 56
2.2.5.8 Phosphate 56
2.2.5.9 Purines 56
2.2.5.10 Urea 56
2.2.6 Middle Molecules 57
2.2.7 Factors Influencing Plasma Concentration of Uremic Solutes 58
2.2.8 Conclusions and Therapeutic Implications 58
References 58
Prerenal Acute Kidney Failure 62
Core Messages 62
2.3.1 Introduction 62
2.3.2 Pathophysiology 63
2.3.3 Causes of Prerenal Acute Kidney Failure 63
2.3.4 Diagnosis of Prerenal Acute Kidney Injury 64
2.3.5 Epidemiology of Prerenal Acute Kidney Failure 64
References 65
Intrinsic Acute Kidney Injury 67
Core MessagesAcute kidney injury (AKI) in the intensive care unit (ICU) can be the result of a wide range of disease proces 67
2.4.1 Epidemiology of AKI in the ICU Focusing on Non-ATN Etiologies 68
2.4.2 Clinical Evaluation of the Critically Ill Patient with AKI 69
2.4.2.1 Acute Prerenal Kidney Injury 69
2.4.2.2 Intrinsic Intrarenal Acute Failure 70
2.4.2.2.1 History and Record Review 71
2.4.2.2.2 Physical Examination 71
Monitoring of Intra-abdominal Pressure 72
2.4.2.2.3 Laboratory Tests 72
Urine Volume 72
Urine Dipstick and Microscopic Examination 73
Urinary Indices 73
Serum Creatinine 74
Serum Cystatin C 75
Biomarkers 75
2.4.2.2.4 Other Laboratory Tests to Establish the Cause of AKI 75
2.4.2.2 Imaging Procedures in the Patient with AKI 76
2.4.2.2.1 Ultrasound 76
2.4.2.2.2 Renal Doppler Ultrasonography 77
2.4.2.2.3 Other Radiologic Investigations 77
2.4.2.2.4 Renal Biopsy 78
2.4.3 Summary of General Therapeutic Principles of AKI in the ICU 78
References 79
Urinary Tract Obstruction 80
Core Messages 80
2.5.1 Introduction 80
2.5.2 Causes of Obstruction 81
2.5.3 Renal Damage Induced by Urinary Tract Obstructions 83
2.5.4 Clinical Signs 84
2.5.5 Diagnostic Approach 85
2.5.6 Instrumental Diagnostics 85
2.5.7 Radiologic Investigations 86
2.5.8 Renal Function After the Removal of an Obstruction 87
2.5.9 Treatment 87
2.5.9.1 Surgical and Instrumental Treatment 87
2.5.9.2 Medical Treatment 88
2.5.9.3 Conclusions 88
References 88
Epidemiology of Acute Kidney Injury 89
Core Messages 89
2.6.1 History 89
2.6.2 Incidence 90
2.6.2.1 Low Threshold Studies 90
2.6.2.2 High Threshold Studies 91
2.6.2.3 AKI Requiring Renal Replacement Therapy 92
2.6.2.4 Age- and Sex-Related Incidence 92
2.6.3 Outcomes 93
2.6.3.1 Mortality 93
2.6.3.2 Mortality in All Forms of AKI 94
2.6.3.3 Mortality in RRT-Dependent AKI 94
2.6.3.4 Mortality of AKI in Intensive Care Units 94
2.6.3.5 Association of Mortality and RIFLE Classification 95
2.6.3.6 Recovery of Renal Function 96
2.6.3.7 Length of Stay and Costs 96
2.6.4 Summary 97
References 97
Economic Impact of Acute Kidney Failure 100
Core Messages 100
2.7.1 Quantifying Costs in the Intensive Care Unit 100
2.7.2 Overview of Studies Reporting Costs Associated with Acute Kidney Injury 100
2.7.3 Clinical Studies of Costs Associated with AKI 103
2.7.4 Take Home Pearls 105
References 105
Diagnostic Evaluation and Procedures 106
Clinical and Laboratory Evaluation 107
Core Messages 107
Objectives to Understand 107
3.1.1 Introduction 107
3.1.2 Presenting Manifestations of AKI 107
3.1.2.1 Clinical 107
3.1.2.2 Laboratory 108
3.1.3 Causes of AKI 110
3.1.4 Evaluation of AKI 111
3.1.4.1 Clinical 111
3.1.4.2 Laboratory 113
3.1.5 Summary 115
References 115
Kidney Function Tests and Urinalysis 118
Core MessagesThe most common surrogates of kidney function are serum creatinine, urea, cystatin C however, these all have 118
3.2.1 Introduction 118
3.2.2 Overview of Kidney Function 119
3.2.3 Assessment of Kidney Function 119
3.2.3.1 Glomerular Filtration Rate 119
3.2.3.2 Serum Markers of Kidney Function in AKI 120
3.2.3.3 Serum Creatinine 120
3.2.3.4 Serum Urea Concentration 120
3.2.3.5 Serum Cystatin C 121
3.2.3.6 Equations to Estimate GFR 122
3.2.3.7 Urinary Tests in Acute Kidney Injury 123
3.2.3.7.1 Urine Output 123
3.2.3.7.2 Urinary Biochemistry and Derived Indices 123
3.2.3.7.3 Urinalysis and Microscopy 124
3.2.3.7.4 Urinary Biomarkers 126
3.2.4 Summary 128
References 128
Renal Ultrasound 132
Core Messages 132
3.3.1 Introduction 132
3.3.2 Ultrasound Basics 133
3.3.3 Anatomy 133
3.3.4 Scanning Techniques 134
3.3.5 Applications 134
3.3.5.1 Hydronephrosis 134
3.3.5.2 Renal Colic 135
3.3.5.3 Pyelonephritis 136
3.3.5.4 Cysts 136
3.3.5.5 Renal Vein Thrombosis 136
3.3.5.6 Renal Infarction 137
3.3.5.7 Masses 137
3.3.5.8 Renal Transplant Evaluation 137
3.3.5.9 Renal Trauma 137
3.3.5.10 Bladder Evaluation 138
3.3.6 Summary 138
References 139
Management of Acute Kidney Problems: Indications for Renal Biopsy in Acute Renal Disease 140
Core MessagesRenal biopsy is the only means of establishing certain diagnoses, many of which may not be suspected from the 140
3.4.1 Introduction 140
3.4.2 Renal Biopsy in Acute Renal Failure 142
3.4.3 Complications of Biopsies 143
3.4.4 Biopsy Processing and Adequacy 144
3.4.5 Conclusions 145
3.4.6 Take Home Pearls 145
References 145
Prevention and ConservativeTherapy of Acute Kidney Failure 146
Volume Resuscitation and Management 147
Core Messages 147
4.1.1 Introduction 147
4.1.2 Risk of Hypervolemia 147
Box 4.1.1 Potential adverse effects of tissue edema 148
4.1.3 Potential Errors in Fluid Management in the Patient with, or at Risk of, Acute Renal Failure 148
4.1.4 How to Assess Fluid Status? 149
Box 4.1.2 Techniques for assessing fluid status and responsivenessStatic techniquesDehydration: Thirst, dry mouth, dry ar 150
4.1.5 Types of Fluids 150
4.1.6 Conclusion 151
4.1.7 Take Home Pearls 151
References 152
Management of Electrolyte Disorders 153
Core Messages 153
4.2.1 Sodium 153
4.2.1.1 Physiology 153
4.2.1.2 Hyponatremia 153
4.2.1.2.1 Management 154
4.2.1.3 Hypernatremia 155
4.2.1.3.1 Management 155
4.2.2 Potassium 156
4.2.2.1 Physiology 156
4.2.2.2 Hypokalemia 156
4.2.2.2.1 Management 156
4.2.2.3 Hyperkalemia 156
4.2.2.3.1 Management 157
4.2.3 Calcium 157
4.2.3.1 Physiology 157
4.2.3.2 Hypocalcemia 158
4.2.3.2.1 Management 158
4.2.3.3 Hypercalcemia 158
4.2.3.3.1 Management 158
4.2.4 Phosphate 159
4.2.4.1 Hyperphosphatemia 159
4.2.4.1.1 Management 159
4.2.4.1.2 Hypophosphatemia 159
4.2.4.1.3 Management 159
4.2.5 Conclusions 160
References 160
Acid–Base Balance 161
Core Messages 161
4.3.1 Introduction 161
4.3.2 The Henderson–Hasselbalch Equation 161
4.3.3 Water and Physical Chemistry 162
4.3.4 Strong Ions 163
4.3.5 Regulation of Plasma Strong Ion Difference 163
4.3.6 Pathophysiology of Strong Ion Imbalance 164
4.3.7 Weak Acids 165
4.3.8 Unmeasured Anions 166
4.3.9 Conclusions 167
References 167
Monitoring and Management of Systemic Hemodynamics* 169
Core Messages 169
4.4.1 Epidemiology 169
4.4.2 Renal Hemodynamic Management  Perspective 169
4.4.3 Renal Perfusion Pressure 169
4.4.4 Hemodynamic Management and  Resuscitation 170
4.4.5 Evaluation for Preload Responsiveness 172
4.4.6 Vasopressor Treatment 172
4.4.6.1 Dopamine 172
4.4.6.2 Norepinephrine 173
4.4.6.3 Epinephrine 173
4.4.6.4 Vasopressin 174
4.4.7 Inotropic Therapy 174
4.4.7.1 Dobutamine 174
4.4.7.2 Milrinone 174
4.4.8 Improve Patient Outcome with Optimizing Oxygen Delivery 175
4.4.9 Conclusion 175
References 175
Treatment of Anemia 177
Core Messages 177
References 181
Metabolic Alterations and Nutrition in AKI 183
4.6.1 Introduction 183
4.6.2 The Metabolic Environment and Nutritional Requirements in Patients with AKI 184
4.6.3 Energy Metabolism and Energy Requirements 184
4.6.4 Carbohydrate Metabolism 185
4.6.5 Lipid Metabolism 185
4.6.6 Protein and Amino Acid Metabolism/Protein Requirements 185
4.6.6.1 Amino Acid and Protein Requirements in AKI 185
4.6.7 Metabolism and Requirements of Micronutrients 186
4.6.8 Electrolytes 186
4.6.9 Metabolic Impact of Renal Replacement Therapy 186
4.6.10 Nutrient Administration 187
4.6.11 Enteral Nutrition (Tube Feeding) 187
4.6.11.1 Enteral Formulas 188
4.6.12 Parenteral Nutrition 188
4.6.12.1 Composition of Parenteral Nutrition Solution 188
4.6.13 Complications of Nutritional Support 189
4.6.14 Conclusions 189
References 190
Glucose, Insulin, and the Kidney 191
Core Messages 191
4.7.1 Introduction 191
4.7.2 Hyperglycemia and Insulin Resistance in the Critically Ill 191
4.7.3 Carbohydrate Metabolism and Transport in the Kidney 191
4.7.4 Diabetic Nephropathy 192
4.7.5 Adverse Effects of Acute Hyperglycemia in the Critically Ill 193
4.7.6 Tight Glycemic Control with Intensive Insulin Therapy in Acute Illness 193
4.7.7 Tight Glycemic Control with Intensive Insulin Therapy and Acute Kidney Injury 194
4.7.7.1 Clinical Data 194
4.7.7.2 Experimental Data 194
4.7.8 Possible Mechanisms of Renoprotection by TGC 195
4.7.8.1 Oxidative Stress 195
4.7.8.2 Nitric Oxide and Nitrosative Stress 195
4.7.8.3 Adhesion Molecules 196
4.7.8.4 Inflammation 197
4.7.8.5 Mitochondrial Damage 197
4.7.8.6 Apoptosis 197
4.7.9 Conclusion (Take Home Message) 198
References 198
Bleeding and Hemostasis 203
Core Messages 203
4.8.1 Basics of Hemostasis 203
4.8.1.1 Humoral Hemostasis 204
4.8.1.2 Cellular Hemostasis 206
4.8.1.3 Vascular Hemostasis 206
4.8.2 The Vascular Endothelium as Central Regulator of Hemostasis 207
4.8.2.1 Modulation of Endothelial Coagulant Properties 207
4.8.2.2 Modulation of Endothelial Permeability 208
4.8.3 Physiologic Anticoagulation and Fibrinolysis 209
4.8.3.1 Anticoagulant Mechanisms 209
4.8.3.2 Fibrinolysis 210
4.8.4 Bleeding Disorders in Acute Care Patients 211
4.8.4.1 Congenital Bleeding Disorders 211
4.8.4.2 Acquired Bleeding Disorders 212
4.8.5 Thromboembolic Disorders 212
4.8.5.1 Venous Thromboembolism and Pulmonary Embolism 212
4.8.5.2 Heparin-Induced Thrombocytopenia 213
4.8.6 Sepsis-Associated Hemostatic Disorders 214
4.8.6.1 Thrombocytopenia 214
4.8.6.2 Disseminated Intravascular Coagulation 215
4.8.7 Take Home Pearls 217
References 217
Neurological Problems 219
Core Messages 219
4.9.1 Introduction 219
4.9.2 Central Nervous System Complications 220
4.9.2.1 Encephalopathy 220
4.9.2.2 Cerebrovascular Disease 222
4.9.2.3 Cognitive Impairment 223
4.9.2.4 Osmotic Myelinolysis 224
4.9.2.5 Movement Disorders and Restless Legs Syndrome 224
4.9.2.6 Opportunistic Infections 224
4.9.2.7 Neoplasms 224
4.9.2.8 Intracranial Hypotension 225
4.9.2.9 Intracranial Hypertension 225
4.9.3 Peripheral Nervous System Complications 225
4.9.3.1 Mononeuropathy 225
4.9.3.2 Polyneuropathy 225
4.9.3.3 Myopathy 225
4.9.4 Conclusion 226
References 226
Gastrointestinal Complications of Acute Kidney Injury 230
Core Messages 230
4.10.1 Introduction 230
4.10.2 Uremic Fetor, Dysgeusia, Anorexia, Dyspepsia, Hiccups, Nausea, and Vomiting 230
4.10.2.1 Anorexia 231
4.10.2.1.1 Treatment 231
(A) Coagulopathy 234
(B) Gastrin 234
(C) Dialysis Treatment 234
(D) Ulcerogenic Drugs 234
4.10.2.2 Hiccups 232
4.10.3 Stomatitis and Salivary Gland Inflammation 232
4.10.4 Uremic Lesions in the Alimentary Tract 232
4.10.5 Gastritis 233
4.10.6 Upper Gastrointestinal Hemorrhage 233
4.10.6.1 Diagnosis and Management of Hemorrhage 234
4.10.7 Diseases of the Small Intestines 236
4.10.7.1 Uremic Enterocolitis 236
4.10.8 Diseases of the Colon 236
4.10.8.1 Ileus 236
4.10.8.2 Intestinal Necrosis 236
4.10.8.3 Colonic Hemorrhage 237
4.10.8.4 Pseudomembranous Colitis 237
4.10.9 Pancreatic Complications 237
4.10.10 Hepatic Disease 238
4.10.11 Cholecystitis 238
4.10.12 Acid–Base and Electrolyte Abnormalities 238
4.10.13 Summary 239
References 239
Cardiovascular Complications of Acute Kidney Injury 242
Core Messages 242
4.11.1 Introduction 242
4.11.2 Differential Diagnosis of Acute Cardiorenal Dysfunction 242
4.11.2.1 Cardiac Problems Causing Acute Kidney Injury 242
4.11.2.1.1 Chronic Cardiac Problems 242
4.11.2.2 Causes of Concomitant Acute Kidney Injury and Cardiac Problems 243
4.11.2.2.1 Toxic Causes 243
4.11.2.2.2 Infectious Diseases 243
4.11.2.2.3 Autoimmune Disease and Vasculitis 243
4.11.2.2.4 Chronic Diseases 244
4.11.2.2.5 Cardiorenal Cross Talk 244
4.11.3 Cardiovascular Complications of Acute Kidney Injury 244
4.11.3.1 Causes and Underlying Pathophysiology 244
4.11.3.1.1 Volume 244
Concept of Diastolic Dysfunction 245
Concept of Diastolic Coronary Perfusion 245
Toxic Causes 246
4.11.3.1.2 Therapeutic Consequences 246
Volume Resuscitation 246
Vasopressor Therapy 246
Pericarditis 247
Cardiac Arrhythmias 247
4.11.4 Conclusion 247
References 248
Acute Kidney Injury: Specific Interventions and Drugs 249
Core Messages 249
4.12.1 Introduction 249
4.12.2 Contrast-Induced Nephropathy 250
4.12.3 Nephrotoxins 250
4.12.4 Specific Interventions for AKI 250
4.12.4.1 Primary Prevention of AKI 250
4.12.4.1.1 Fluid Therapy 250
4.12.4.1.2 Vasodilators 250
4.12.4.1.3 Diuretics 252
4.12.4.1.4 Antioxidants 252
4.12.4.1.5 Statins 252
4.12.4.1.6 Blood Purification 252
4.12.4.1.7 Lessons from Primary Prevention 253
4.12.5 Secondary Prevention and Treatment of AKI 253
4.12.5.1 Hemodynamic Optimization – Cardiac Output 253
4.12.5.2 Vasopressor Therapy 253
4.12.5.3 Renal Vasodilators 254
4.12.5.4 Diuretics 254
4.12.5.5 Cytoprotection 254
4.12.5.6 Antiinflammatory Agents 255
4.12.6 Specific Situations 255
4.12.6.1 Hepatorenal Syndrome 255
4.12.6.2 Abdominal Compartment Syndrome 255
4.12.6.3 Rhabdomyolysis 256
4.12.6.4 Limitation of Specific Interventions 256
4.12.7 Take Home Pearls 256
References 256
Drug Dosing in Acute Kidney Injury and During Renal Replacement Therapy 260
Core Messages 260
4.13.1 Drug Dosing in Acute Kidney Injury and During Renal Replacement Therapy 260
4.13.1.1 Pharmacokinetic Changes During Acute Kidney Injury 261
4.13.1.1.1 Absorption 261
4.13.1.1.2 Distribution 261
4.13.1.1.3 Metabolism 262
4.13.1.1.4 Elimination 262
4.13.1.2 Drug Dosing in Acute Kidney Injury 263
4.13.1.2.1 Drug Dosing in Acute Kidney Injury with No Renal Replacement Therapy 264
4.13.1.2.2 Drug Dosing in Acute Kidney Injury Treated with Renal Replacement Therapies 265
4.13.1.3 Approach to Patient Care 266
4.13.2 Take Home Pearls 267
References 267
Anesthesia in Patients with Kidney Failure 271
Core Messages 271
4.14.1 Introduction 271
4.14.2 Preoperative Evaluation 271
4.14.2.1 Intraoperative Management in Renal Failure Patients 272
4.14.2.1.1 Monitoring 272
4.14.2.2 Selection of Anesthetic Drugs 273
4.14.2.3 Fluid Management 273
4.14.3 Postoperative Management 274
4.14.4 Prevention of Perioperative Acute Kidney Failure 274
4.14.4.1 Patient-Related Factors 274
4.14.4.2 Surgical Procedures 274
4.14.5 Management of High-Risk Patients 274
4.14.5.1 Fluid and Electrolyte Homeostasis 274
4.14.5.2 Pharmacological Therapy 275
4.14.6 Take Home Pearls 275
References 275
Long-Term Outcome of AcuteKidney Injury 277
Long-Term Outcome of Acute Kidney Injury 278
5.1.1 Introduction 278
5.1.2 ICU and Hospital Mortality 278
5.1.3 Factors Predicting Hospital Survival 279
5.1.4 Long-Term Prognosis 279
5.1.5 Recovery of Renal Function 281
5.1.6 Quality of Life 281
5.1.7 Conclusion 282
References 282
Diagnosis and Managementof Specific Disorders 285
Acute Kidney Injury in Sepsis 287
Core Messages 287
6.1.1 Hemodynamics and Hormones During Sepsis and Acute Kidney Injury 287
6.1.2 Sodium and Water Balance During Sepsis 288
6.1.3 Early Renal Vasoconstriction in Septic AKI 289
6.1.4 Role of Oxygen Radicals and Cytokines in Renal Tubular and Vascular Injury During Sepsis 290
6.1.5 Prospective Randomized Clinical Studies in Sepsis 291
6.1.6 Take Home Pearls 294
References 294
Kidney in Acute Heart Failure and Cardiogenic Shock 296
Core Messages 296
6.2.1 Introduction 296
6.2.2 Brief Review of Renal Neurohormonal Regulation 296
6.2.3 Clinical Aspects in the Management of AHFS and Cardiogenic Shock 297
6.2.4 Mechanical Circulatory Support in Cardiogenic Shock and its Effects on Renal Function 298
6.2.5 Role of Continuous Renal Replacement Therapy in Cardiogenic Shock 299
6.2.6 Take Home Pearls 299
References 299
Acute Kidney Problems in Congestive Heart Failure 301
Core Messages 301
6.3.1 Introduction 301
6.3.2 Congestive Heart Failure 302
6.3.3 Cardiorenal Syndrome 303
6.3.4 Deterioration in Renal Function During Management of Acute Decompensated Heart Failure 303
6.3.5 Risk of Rhabdomyolysis with Statins 305
6.3.6 Cholesterol Embolization 306
6.3.7 Radiocontrast Nephropathy 306
6.3.8 Special Circumstances 307
6.3.8.1 Renovascular-Induced Heart Failure 307
6.3.8.2 Scleroderma-Induced Heart Failure 307
6.3.8.3 Heart Failure in Dialysis and Renal Transplant Patients 308
6.3.8.4 Renal Dysfunction in the Heart Transplant Recipient 308
6.3.9 Take Home Pearls 308
References 309
Hepatorenal Syndrome 310
Core Messages 310
6.4.1 Definition 310
6.4.2 Pathophysiology 311
6.4.3 Diagnosis 311
6.4.3.1 Diagnostic Criteria 311
6.4.3.2 Renal Biopsy 312
6.4.3.3 Differential Diagnosis 312
6.4.4 Treatment 312
6.4.4.1 Prevention 312
6.4.4.2 Pharmacologic Interventions 313
6.4.4.3 Transjugular Intrahepatic Portosystemic Shunt 314
6.4.4.4 Renal Replacement Therapy 314
6.4.4.5 Extracorporeal Liver Support 315
6.4.4.6 Liver Transplantation 315
6.4.5 Take Home Pearls 316
References 316
Malignant Hypertension 318
Core Messages 318
6.5.1 Introduction 318
6.5.2 Histopathologic Findings 319
6.5.3 Pathophysiology 319
6.5.3.1 Sodium Depletion and Pressure-Induced Natriuresis 320
6.5.3.2 Renovascular Ischemia and Vascular Damage 320
6.5.4 Epidemiology 321
6.5.5 Clinical Perspectives 322
6.5.6 Management 323
6.5.6.1 General Recommendations 323
6.5.6.2 Specific Therapy 324
6.5.6.3 Specific Conditions 326
6.5.7 Take Home Pearls 327
References 327
Toxic Nephropathy Due to Drugs and Poisons 330
Core Messages 330
6.6.1 Introduction 330
6.6.2 Pathophysiologic Mechanisms 332
6.6.2.1 Altered Renal Hemodynamics 332
6.6.2.2 Acute Tubular Necrosis 332
6.6.2.3 Allergic Interstitial Nephritis 332
6.6.2.4 Vasculopathy 333
6.6.2.5 Obstructive Tubulopathy 333
6.6.2.6 Osmotic Nephrosis 333
6.6.3 Common Nephrotoxins 334
6.6.3.1 Aminoglycoside Antibiotics 334
6.6.3.2 Amphotericin B 334
6.6.3.3 Angiotensin-Converting Enzyme Inhibitors and Angiotensin II Receptor Blockers 335
6.6.3.4 Calcineurin Inhibitors 335
6.6.3.5 Colloids 336
6.6.3.6 Ethylene Glycol 336
6.6.3.7 Myoglobin (Pigment) 336
6.6.3.8 Nonsteroidal Antiinflammatory Drugs 337
6.6.3.9 Paraquat 337
6.6.3.10 Radiocontrast Agents 338
6.6.3.11 Vancomycin 338
6.6.4 Conclusion 339
6.6.5 Take Home Pearls 339
References 339
Toxic Nephropathy Due to Radiocontrast Media* 342
Core Messages 342
6.7.1 Definition of Toxic Nephropathy After Iodinated Contrast Medium 342
6.7.2 Consensus Statements on Contrast-Induced Acute Kidney Injury 342
6.7.3 Pathophysiology 343
6.7.4 Classes of Iodinated Contrast 345
6.7.5 Importance of Volume Expansion 345
6.7.6 Dialysis and Hemofiltration 346
6.7.7 Pharmacologic Prophylaxis 346
6.7.8 Follow-Up 346
6.7.9 Biomarkers for Contrast-Induced AKI 346
6.7.10 Future Approaches 347
6.7.11 Take Home Pearls 347
References 347
Acute Glomerulonephritis, Vasculitis, and Pulmonary Renal Syndrome 350
Core Messages 350
6.8.1 Introduction 350
6.8.2 Causes of ARF Due to Glomerulonephritis/Vasculitis 350
6.8.3 Causes of ARF Due to Glomerulonephritis 351
6.8.4 Acute Renal Failure in Vasculitis 352
6.8.5 Pathogenesis of ARF in Glomerulonephritis/Vasculitis 353
6.8.6 Clinical Features 353
6.8.7 Acute Renal Failure in Patients with Underlying Glomerulonephritis 354
6.8.8 Acute Renal Failure Complicating Nephrotic Syndrome 354
6.8.9 Treatment and Prognosis of Glomerulonephritis/Vasculitis – Associated Acute Renal Failure 355
6.8.10 The Pulmonary Renal Syndrome 356
6.8.11 Take Home Pearls 357
References 358
Hemolytic Uremic Syndrome/Thrombotic Thrombocytopenic Purpura 361
Core Messages 361
6.9.1 Introduction 361
6.9.2 Acquired Forms 361
6.9.2.1 Shigatoxin (Stx)–Associated-HUS 361
6.9.2.1.1 Supportive Therapy 362
6.9.2.1.2 Shigatoxin-Binding Agents 363
6.9.2.1.3 Plasma Manipulation and Other Specific Treatments 363
6.9.2.1.4 Kidney Transplantation 363
6.9.2.2 Neuraminidase Associated–HUS 363
6.9.2.2.1 Therapy 363
6.9.2.3 HUS Associated with Immune-Mediated Defective Activity of Complement Regulatory Proteins 363
6.9.2.3.1 Treatment 364
6.9.2.4 TTP Associated withImmune-Mediated Deficiency of VWF-Cleaving Protease (ADAMTS13) Activity 364
6.9.2.4.1 Supportive Therapy, Plasma Manipulation, and Other Specific Treatments 364
6.9.2.4.2 Rescue Treatments 365
6.9.2.5 Pregnancy Associated-TMA 365
6.9.2.5.1 TTP 365
6.9.2.5.2 The HELLP Syndrome 366
6.9.2.5.3 Postpartum HUS 366
6.9.2.6 Systemic Disease–AssociatedTMA 366
6.9.2.7 Drug-Associated TMA 366
6.9.2.7.1 Mitomycin and Anticancer Drugs 366
6.9.2.7.2 Antiplatelet Drugs 367
6.9.2.7.3 Quinine 367
6.9.2.8 Bone Marrow and Solid Organ Transplant Associated HUS 367
6.9.2.8.1 De Novo Posttransplant HUS 367
6.9.3 Genetic (TMA Associated with Congenital Defects) 368
6.9.3.1 HUS Associated with Genetic Abnormalities in Complement Regulatory Proteins 368
6.9.3.1.1 Therapy 369
6.9.3.1.2 Transplantation 369
6.9.3.2 TTP Associated with Congenital Deficiency of ADAMTS13 370
6.9.3.2.1 Therapy 370
6.9.3.3 HUS Associated with Inborn Abnormal Cobalamin Metabolism 370
6.9.3.3.1 Therapy 371
6.9.3.4 Other Genetic Forms 371
6.9.3.4.1 Therapy 371
6.9.4 Idiopathic 371
6.9.4.1 Therapy 371
6.9.5 Treatment Guidelines 371
6.9.5.1 Plasma Manipulation 371
6.9.5.2 Other Specific Treatments 372
6.9.5.3 Rescue Treatments 372
6.9.6 Future Directions 372
6.9.7 Take Home Pearls 372
References 373
Acute Tubulointerstitial Nephritis 377
6.10.1 Background 377
6.10.2 Historical 377
6.10.3 Epidemiology 378
6.10.4 Clinical Features 378
6.10.5 Etiology 378
6.10.5.1 Drug-Induced ATIN 378
6.10.5.1.1 NSAID-Associated DI-ATIN 379
6.10.5.2 Infection-Related ATIN (IR-ATIN) 379
6.10.5.3 Autoimmune ATIN 379
6.10.5.4 Idiopathic ATIN 379
6.10.5.5 Tubulointerstitial Nephritis and Uveitis Syndrome 380
6.10.5.6 Renal Transplant ATIN 380
6.10.6 Pathogenesis 380
6.10.7 Histology 380
6.10.8 Diagnosis 381
6.10.9 Treatment 381
6.10.10 Prognosis 382
6.10.11 Take Home Pearls 382
References 383
Myoglobinuric Acute Kidney Failure 385
Core Messages 385
6.11.1 Introduction 385
6.11.1.1 Structure of the Muscles 386
6.11.2 Etiology and Pathogenesis 386
6.11.2.1 Etiology of Rhabdomyolysis 386
6.11.2.2 Pathogenesis of Rhabdomyolysis 387
6.11.2.3 Pathogenesis of Myoglobinuric AKF 387
6.11.3 Clinical Findings 388
6.11.4 Laboratory Findings 388
6.11.4.1 Urinary Findings 388
6.11.4.2 Biochemical Features 389
6.11.5 Prognosis 390
6.11.6 Prophylaxis 390
6.11.7 Treatment 391
6.11.8 Take Home Pearls 392
References 392
Tropical Infections and Acute Kidney Injury 395
Core Messages 395
6.12.1 Introduction 395
6.12.2 Pathogenetic Mechanisms 398
6.12.2.1 Direct Invasion 398
6.12.2.2 Systemic Inflammatory Response 398
6.12.2.3 Hemodynamic Perturbation 398
6.12.2.4 Immune-Mediated Renal Lesions 398
6.12.2.5 Iatrogenic Renal Injury 399
6.12.3 Clinical Characteristics 400
6.12.4 Diagnosis 400
6.12.5 Management 400
6.12.6 Take Home Pearls 401
References 401
AIDS and Acute Kidney Failure 404
Core MessagesHIV-infected patients may present with a variety of patterns of renal involvementAcute kidney failure (AK 404
6.13.1 Epidemiology: Incidence and Risk Factors 404
6.13.2 Causes 405
6.13.2.1 Prerenal and/or ATN 405
6.13.2.2 Postrenal AKF 406
6.13.3 Intrinsic Renal Failure 406
6.13.3.1 Acute Interstitial Nephritis 406
6.13.3.2 Thrombotic Microangiopathy 407
6.13.3.3 Acute Glomerulopathies 407
6.13.3.4 Drug Related AKF 408
6.13.3.5 Drug-Induced Acute Crystal Nephropathy 408
6.13.3.6 Rhabdomyolysis 408
6.13.4 Underlying Mechanisms 409
6.13.5 Conclusion 410
6.13.6 Take Home Pearls 410
References 411
Acute Kidney Injury in Oncological Disorders and Tumor Lysis Syndrome 414
Core Messages 414
6.14.1 Introduction 414
6.14.2 Negative Impact of AKI on Prognosis for Cancer Patients 414
6.14.3 Causes of AKI in Cancer Patients 415
6.14.3.1 Nephrotoxic Chemotherapy Agents 415
6.14.3.1.1 Mitomycin C 415
6.14.3.1.2 Gemcitabine 416
6.14.3.1.3 Platinum Compounds 416
6.14.3.1.4 Methotrexate 416
6.14.3.1.5 Alkylating Agents 417
6.14.3.2 Urinary Tract Obstruction or Infiltration of The Kidney By Tumors 417
6.14.3.3 Tumor Lysis Syndrome 417
6.14.3.4 Uric Acid 418
6.14.3.5 AKI in Patients with Multiple Myeloma 419
6.14.3.6 AKI in Patients Given Hematopoietic Progenitor Cell Transplants 419
6.14.3.7 Viral Infections 420
6.14.4 Conclusions 420
6.14.5 Take Home Pearls 421
References 421
Kidney Failure Following Cardiovascular Surgery 423
Core Messages 423
6.15.1 Introduction 423
6.15.2 Epidemiology and Outcome 423
6.15.3 Risk Factors 424
6.15.3.1 Patient-Related Risk Factors 424
6.15.3.2 Procedure-Related Risk Factors 425
6.15.4 Pathomechanisms 425
6.15.4.1 Preoperative Events 425
6.15.4.2 Intraoperative Events 426
6.15.4.3 Postoperative Events 427
6.15.4.4 Diagnosis 427
6.15.5 Prevention 427
6.15.5.1 Hemodynamic Strategies 428
6.15.5.2 Pharmacologic Strategies 428
6.15.5.3 Nonpharmacologic Strategies 429
6.15.6 Treatment 432
6.15.7 Summary 433
6.15.8 Take Home Pearls 434
References 434
Burns and Acute Kidney Failure 439
Core Messages 439
6.16.1 Introduction 439
6.16.2 Pathophysiology of Burns 439
6.16.2.1 Thermal Injury 439
6.16.2.2 Chemical Injury 440
6.16.2.3 Electrical Injury 440
6.16.2.4 Inhalation-Associated Injury 440
6.16.2.5 Fluid Management and Prevention of Septic Complications 440
6.16.3 Renal and Electrolyte Abnormalities 441
6.16.3.1 Renal Blood Flow and Glomerular Filtration Rate Changes 441
6.16.3.2 Tubular and Electrolyte Alterations 441
6.16.3.3 Hematuria and Proteinuria 441
6.16.4 Acute Renal Failure 442
6.16.4.1 Incidence and Prognosis 442
6.16.4.2 Early Acute Renal Failure 443
6.16.4.3 Late Acute Renal Failure 443
6.16.5 Renal Replacement Therapy in Burn Patients 444
6.16.5.1 Early Experiences of Dialysis 444
6.16.5.2 Dialysis Data in the Last 20 Years 444
6.16.6 Take Home Pearls 445
References 445
Acute Kidney Transplant Failure 448
Core Messages 448
6.17.1 Introduction 448
6.17.2 Clinical Approach and Diagnostic Procedures 449
6.17.2.1 History 449
6.17.2.2 The Patient with Fever or Inflammation 449
6.17.2.3 Diarrhea 450
6.17.2.4 Ultrasound 450
6.17.2.5 Allograft Biopsy 451
6.17.3 Take Home Pearls 452
References 452
Acute Kidney Failure During Pregnancy and Postpartum 453
Core Messages 453
6.18.1 Introduction and Scope 453
6.18.1.1 Physiology of Maternal Renal Adaptation During Pregnancy 454
6.18.2 Diagnosis 454
6.18.3 Preeclampsia/Eclampsia/HELLP Syndrome 455
6.18.3.1 Preeclampsia 455
6.18.3.2 Eclampsia 456
6.18.3.3 HELLP Syndrome 457
6.18.4 Thrombotic Microangiopathies 457
6.18.5 SLE and Antiphospholipid Syndrome 457
6.18.6 Sepsis 458
6.18.7 Therapeutic Principles 458
6.18.7.1 Drug Choice and Drug Dosing 458
6.18.7.1.1 Antihypertensives 458
6.18.7.1.2 Antibiotics 459
6.18.7.1.3 Erythropoietin 459
6.18.7.1.4 Anticoagulants 459
6.18.7.1.5 Loop Diuretics 459
6.18.7.2 Renal Replacement Therapy 459
6.18.7.2.1 Beginning of Renal Replacement Therapy 460
6.18.7.2.2 Choice of Modality of Renal Replacement Therapy 460
6.18.7.2.3 Dose of Renal Replacement Therapy 461
6.18.7.2.4 Practical Problems of Renal Replacement Therapy 461
6.18.7.2.5 Nonrenal Indications for Extracorporeal Treatment in Peripartum Patients 462
6.18.8 Prenatal and Obstetric Management 462
6.18.8.1 Monitoring of Mother and Child 462
6.18.8.2 Doppler Velocimetry and Fetal Heart Tracings 462
6.18.8.3 Decision for Timing and Mode of Delivery 463
6.18.9 Take Home Pearls 463
References 464
Acute Kidney Failure in Children 467
Core Messages 467
6.19.1 Introduction 467
6.19.2 Epidemiology 467
6.19.3 Etiology and Diagnosis 468
6.19.4 Treatment 469
6.19.4.1 Fluid and Electrolyte Considerations 469
6.19.4.2 Pharmacologic Therapy 470
6.19.4.2.1 Vasopressors 470
6.19.4.3 Renal Replacement Therapy 470
6.19.4.4 Vascular Access 471
6.19.4.5 Patient Factors 472
6.19.4.6 Crrt 472
6.19.5 Specific Patient Populations 473
6.19.5.1 Infants 473
6.19.5.2 Congenital Heart Disease 473
6.19.5.3 Multiorgan Dysfunction Syndrome 473
6.19.5.4 Stem Cell Transplantation 473
6.19.6 Outcome 473
6.19.7 Take Home Pearls 474
References 474
Temporary Replacementof Kidney Function 476
Indications to Start Kidney Replacement Therapy 477
Core Messages 477
7.1.1 Introduction 477
7.1.2 Electrolyte Disorders 478
7.1.2.1 Hyperkalemia 478
7.1.2.2 Hypo- and Hypernatremia 478
7.1.2.3 Hypercalcemia 478
7.1.3 Acid–Base Disorders 478
7.1.4 Fluid Management 478
7.1.4.1 Volume Overload and Oligoanuria 478
7.1.4.2 Loop Diuretics 479
7.1.4.3 Trials on Timing of Dialysis 480
7.1.4.4 Summary 480
7.1.5 Azotemia 481
7.1.6 Conclusion 483
References 484
Principles of Extracorporeal Therapy: Haemodialysis, Haemofiltration and Haemodiafiltration 486
7.2.1 Introduction 486
7.2.2 A Brief History of Dialysis 486
7.2.3 Physiological Principles 487
7.2.3.1 Diffusion 488
7.2.3.2 Osmosis 488
7.2.3.3 Convection 488
7.2.3.4 Combining Diffusion and Convection 488
7.2.4 Membrane and Dialysers 488
7.2.5 Dialysis Fluid 489
7.2.6 The Dialysis Machine 490
7.2.6.1 The Dialysis Fluid Pathway 490
7.2.6.2 The Extracorporeal Circuit 490
7.2.6.3 Other Features of HD Machines 491
7.2.7 Anticoagulation 491
7.2.8 Haemodialysis/Filtration Techniques 491
7.2.8.1 Conventional Haemodialysis 491
7.2.8.2 Haemofiltration 492
7.2.8.3 High-flux Haemodialysis 492
7.2.8.4 Haemodiafiltration 492
7.2.8.5 Other Haemodialysis Techniques Applicable to AKF 493
7.2.8.5.1 Sustained Low-Efficiency Dialysis 493
7.2.8.5.2 HVHF and PHVHF 493
7.2.8.5.3 Renal Assist Device 493
7.2.9 Adequacy of Dialysis 493
7.2.10 Take Home Pearls 494
References 494
Membranes for Dialysis and Hemofiltration 495
Core Messages 495
7.3.1 Introduction 495
7.3.2 Classification of Dialysis Membranes 496
7.3.3 Dialysis Membrane Materials 496
7.3.3.1 Cellulose Membranes 496
7.3.3.2 Modified Cellulosic Membranes 497
7.3.3.3 Synthetic Membranes 498
7.3.4 Dialysis Membrane Biocompatibility 500
7.3.5 Dialysis Membrane Biocompatibility and Clinical Outcome 502
7.3.6 Dialysis Membrane Permeability and Clinical Outcome 503
7.3.7 Dialysis Membrane Requirements in Acute Renal Failure 503
7.3.8 Future Trends in Dialysis Membranes: The Bioartificial Kidney 506
7.3.9 Take Home Pearls 506
References 506
Dialysates and Substitution Fluids 510
Core Messages 510
7.4.1 Introduction 510
7.4.2 Fluids for CRRT 511
7.4.3 Choice of Buffer 512
7.4.4 Citrate Anticoagulation 513
7.4.5 Influence of CRRT Prescription 514
7.4.6 Temperature 515
7.4.7 High Volume Hemofiltration 515
7.4.8 Take Home Pearls 515
References 515
Intermittent Hemodialysis 517
7.5.1 Introduction 517
7.5.2 Operational Characteristics of IHD 518
7.5.2.1 Physical Principles 518
7.5.2.2 Technical Aspects 518
7.5.2.2.1 Dialysis Machine 518
7.5.2.2.2 Pure Water 518
7.5.2.2.3 Dialysate 518
7.5.2.2.4 Vascular Access 519
7.5.2.2.5 Dialysis Membrane 519
7.5.2.2.6 Anticoagulation 519
7.5.3 Advantages and Limits 519
7.5.4 Different Modalities 520
7.5.4.1 Conventional IHD 520
7.5.4.2 Sequential IHD 520
7.5.4.3 Sustained Low-Efficiency Dialysis 520
7.5.5 Specificity of IHD Use in ICU 520
7.5.5.1 Metabolic Control and Dialysis Dose 521
7.5.5.2 Hemodynamic Tolerance 522
7.5.5.3 Outcome Improvement or Renal Recovery 522
7.5.6 Preferential Indication for IHD 523
7.5.6.1 ARF Complications 523
7.5.6.2 Hyperkalemia 523
7.5.6.3 Metabolic Acidosis 523
7.5.6.4 Azotemia 523
7.5.6.5 Poisoning 523
7.5.6.6 Hemorrhage Risk and Contraindications to Anticoagulant 523
7.5.6.7 Other Indications 524
7.5.7 Take Home Pearls 524
References 524
Continuous Renal Replacement Therapies 526
Core Messages 526
7.6.1 Introduction 526
7.6.2 Historical Review 527
7.6.3 CRRT Techniques and Nomenclature 527
7.6.3.1 Arteriovenous and Venovenous Circuits 527
7.6.3.2 Hemofiltration, Hemodialysis, and Hemodiafiltration 527
7.6.3.3 Predilution and Postdilution 529
7.6.3.4 Anticoagulation 530
7.6.3.5 Dose 531
7.6.3.6 Other Technical Aspects of CRRT 531
7.6.4 Indications and Timing of Starting CRRT 532
7.6.5 Nonrenal Indications of CRRT 532
7.6.6 Complications/Problems 533
7.6.7 CRRT Versus IRRT 534
7.6.8 Take Home Pearls 534
References 535
Extended Daily Dialysis 537
Core Messages 537
7.7.1 Extended Dialy Dialysis: Back to the Roots of Renal Replacement Therapy in Critically Ill Patients 537
7.7.2 What Led to the Revival of EDD in the ICU? 538
7.7.3 Clinical Experience with EDD Therapy of Critically Ill Patients with AKI 538
7.7.4 Quantifying the Dose of EDD and Survival with EDD 540
7.7.5 Technical Modifications of the EDD Technique 541
7.7.6 The Genius Batch Dialysis System 541
7.7.7 Removal of Drugs and Toxins 542
7.7.8 Economic Considerations 542
7.7.9 EDD: The “Hybrid” Approach in Terms of Techniques and Specialties 542
7.7.10 Summary and Outlook 543
7.7.11 Take Home Pearls 543
References 543
Quantifying the Dose of Acute Kidney Replacement Therapy 546
Core Messages 546
7.8.1 Introduction 546
7.8.2 Meaning and Different Approaches to RRT Dose 546
7.8.3 RRT Dose Adequacy: Does It Exist? 548
7.8.4 RRT Dose Delivery: Continuous, Intermittent, Hybrid 550
7.8.5 Conclusions 553
7.8.6 Take Home Pearls 554
References 554
Anticoagulation for Acute Dialysis 557
Core Messages 557
7.9.1 Introduction 557
7.9.1.1 Why Do Renal Replacement Therapy Circuits Clot ? 558
7.9.1.2 Design of the Extracorporeal Circuit 559
7.9.1.3 Anticoagulant-Free Renal Replacement Therapy 560
7.9.1.3.1 Unfractionated Heparin 560
Regional Heparinization 561
Recombinant Antithrombin and Unfractionated Heparin 562
Low-Molecular-Weight Heparins 562
Heparin-Coated Extracorporeal Circuits 563
Heparin-Induced Thrombocytopenia 563
Dermatan Sulphate and Danaparoid 563
Heparinoids 564
Prostacyclin 565
Direct Thrombin Inhibitors: Hirudin and Argatroban 565
Nafamostat Mesilate 566
7.9.1.3.2 Citrate 566
7.9.1.3.3 Activated Protein C 569
7.9.2 Summary 569
7.9.3 Take Home Pearls 570
References 570
Vascular Access for Acute Dialysis 574
7.10.1 Introduction 574
7.10.2 How to Choose a CVC for Acute Dialysis? 575
7.10.2.1 CVC Material and Design 575
7.10.2.2 CVC Design and Function 576
7.10.2.3 Patient Clinical Condition and Dialysis Modality 577
7.10.3 How to Insert, Care and Manage a Dialysis CVC? 579
7.10.4 How to Evaluate and to Improve Dialysis CVC Performances? 581
7.10.5 How to Improve CVC Outcomes in Intensive Care Unit Setting? 581
7.10.6 Conclusion 583
7.10.7 Take Home Pearls 583
References 584
Principles and Practice of Acute Peritoneal Dialysis 587
Core Messages 587
7.11.1 Introduction 587
7.11.2 Advantage of PD for ARF 588
7.11.3 Disadvantages of PD 588
7.11.4 Outcome of Using PD in Acute Renal Failure 589
7.11.5 Forms of PD Available 590
7.11.5.1 Intermittent Peritoneal Dialysis 590
7.11.5.2 Continuous Peritoneal Dialysis/Continuous Equilibrated Peritoneal Dialysis 590
7.11.5.3 Continuous Flow Peritoneal Dialysis 590
7.11.5.4 Tidal Peritoneal Dialysis 590
7.11.6 Types of Peritoneal Dialysis Catheters for Acute Peritoneal Dialysis 591
7.11.6.1 Semirigid Straight Uncuffed Catheters 591
7.11.6.2 Cuffed Flexible Silicone Catheters (Tenckhoff Catheter) 591
7.11.7 Implantation Technique of Cuffed Silicone PD Catheters 591
7.11.8 The Peritoneal Dialysate 592
7.11.9 The Dialysis Prescription 592
7.11.9.1 Achieving Fluid Removal Target 592
7.11.9.2 Achieving Adequate Uremic Toxin Removal 593
7.11.10 Complications of Acute Peritoneal Dialysis 593
7.11.10.1 Peritonitis 593
7.11.10.2 Catheter-Related Infection 594
7.11.10.3 Complications Related to Catheter Insertion 594
7.11.10.4 Obstruction of Flow 595
7.11.10.5 Increased Intraperitoneal Pressure 595
7.11.10.6 Hyperglycemia 595
7.11.10.7 Hypernatremia 595
7.11.10.8 Hypokalemia 595
7.11.10.9 Metabolic Acidosis 595
7.11.11 Take Home Pearls 596
Appendix 596
References 596
Choosing a Therapy Modality for Acute Renal Replacement Therapy 598
Core Messages 598
7.12.1 Introduction 598
7.12.2 The “Evidence-Base”: Clinical Studies Comparing Outcomes of CRRT and IRRT 599
7.12.3 The Clinical Choice of Treatment Modalities 600
7.12.4 Diffusive Versus Convective Treatment Strategies 601
7.12.5 Take Home Pearls 602
References 602
Acute Kidney Replacement Therapy in Children 603
Core Messages 603
7.13.1 Introduction 603
7.13.2 Peritoneal Dialysis 603
7.13.2.1 Advantages 603
7.13.2.2 Disadvantages 604
7.13.2.3 Indications 604
7.13.2.4 Technique 604
7.13.2.5 Adequacy and Outcome 604
7.13.2.6 Complications 605
7.13.3 Intermittent Hemodialysis 605
7.13.3.1 Advantages 605
7.13.3.2 Disadvantages 605
7.13.3.3 Indications 606
7.13.3.4 Technique 606
7.13.3.5 Adequacy and Outcome 607
7.13.3.6 Complications 607
7.13.4 Continuous Renal Replacement Therapy 607
7.13.4.1 Advantages 607
7.13.4.2 Disadvantages 607
7.13.4.3 Indications 607
7.13.4.4 Technique 608
7.13.4.5 Adequacy and Outcome 609
7.13.4.6 Complications 609
7.13.5 Summary/Conclusions 609
7.13.6 Take Home Pearls 609
References 609
Stopping Acute Kidney Replacement Therapy 611
Core Messages 611
7.14.1 Introduction 611
7.14.1.1 Stopping RRT: Key Concepts 611
7.14.1.2 RRT Cessation: When to Stop? 612
7.14.1.2.1 Improvement in Underlying Renal Function (Renal Replacement Indications) 612
Hyperkalemia 612
Metabolic Acidosis 613
Progressive Azotemia 613
Volume Overload 615
Poisoning and Drug Toxicity 615
7.14.1.2.2 Improvement in Basic Disorder Requiring RRT (Renal Support Indications) 615
Relative Volume Overload 615
Hypercatabolism 615
7.14.1.2.3 Futility 616
7.14.1.3 RRT Cessation: How to Stop? 616
7.14.1.4 Monitoring Treatment Cessation 617
7.14.2 Take Home Pearls 617
References 618
Extracorporeal Therapiesfor Nonrenal Indications 620
Extracorporeal Therapies and Immunomodulation During Sepsis 621
Core Messages 621
8.1.1 Introduction 621
8.1.2 The Immunopathogenesis of Sepsis: A Role for an Extracorporeal Intervention? 621
8.1.3 Continuous Renal Replacement Techniques and EBT in Sepsis 622
8.1.4 High-Volume Hemofiltration 623
8.1.5 High Cutoff Dialysis/Hemofiltration and High-Flux Dialysis 624
8.1.6 Plasmapheresis/Plasma Separation 624
8.1.7 Adsorption: Hemoperfusion and Plasma Separation/Adsorption 624
8.1.8 Direct Hemoperfusion/Adsorption 625
8.1.9 Coupled Plasma Filtration Adsorption 625
8.1.10 Plasma Filtration/Selective Adsorption 625
8.1.11 Conclusions 626
8.1.12 Take Home Pearls 626
References 626
Extracorporeal Liver Support 629
Core Messages 629
8.2.1 Introduction 629
8.2.2 Artificial Liver Support 630
8.2.3 Bioartificial Liver Support 632
8.2.4 Discussion 634
8.2.5 Take Home Pearls 635
References 636
Extracorporeal Removal of Drugs and Toxins 638
Core Messages 638
8.3.1 Introduction 638
8.3.2 Criteria and Considerations for Extracorporeal Therapy 639
8.3.3 Principles of Extracorporeal Removal of Drugs and Toxins 639
8.3.4 Extracorporeal Modalities – Hemodialysis 642
8.3.5 Extracorporeal Modalities – Hemofiltration and Hemodiafiltration 642
8.3.6 Extracorporeal Modalities – Hemoperfusion 643
8.3.7 Extracorporeal Modalities – Peritoneal Dialysis 643
8.3.8 Extracorporeal Modalities – Plasma Exchange and Exchange Transfusion 643
8.3.9 Specific Drugs/Poisons 645
8.3.9.1 Lithium 645
8.3.9.2 Salicylates 645
8.3.9.3 Methanol 646
8.3.9.4 Ethylene Glycol 646
8.3.10 Take Home Pearls 647
References 647
Subject Index 651