Renal Failure In Intensive Care Unit Research Articles

Efficacy of Continuous Renal Replacement Therapy and Intermittent Hemodialysis in Patients with Renal Failure in Intensive Care Unit: A Systemic Review and Meta‐analysis

This study aimed to compare the clinical efficacy of continuous renal replacement therapy (CRRT) and intermittent hemodialysis (IHD) in patients with renal failure in intensive care unit (ICU). Relevant studies were searched in the databases including EMBASE, Cochrane Library, and MEDLINE (PubMed) from inception to January 04, 2021. The inclusion of available studies and the collection of data were independently conducted by two authors after reviewing the full text. Pooled analyses of relative risk (RR) and weighted mean difference (WMD) were performed to compare the outcomes of renal recovery, short-term mortality, length of ICU stays, and length of in-hospital stays between the two different treatment groups. Publication bias was assessed by the funnel plot. A total of 11 RCT studies including 1740 patients with renal failure were eligible for final analysis. Among them, 894 patients (51.4%) underwent CRRT and 846 patients (48.6%) received IHD. Pooled analysis did not find significant differences in renal recovery and short-term mortality between the two groups. Interestingly, patients underwent CRRT showed significantly shorter length of ICU stay and in-hospital stay than those who underwent IHD (ICU stay: RR: -0.61, 95%CI: -1.10--0.11, P < 0.05; I2 = 93.6%; in-hospital stay: RR: -0.56, 95%CI: -1.41-0.28, P < 0.05; I2 = 97.7%). No significant publication biases were observed on the funnel plots. Compared with IHD, CRRT had similar effects on renal recovery and short-term mortality in patients with renal failure in ICU. As a promising technique in clinical practice, CRRT could significantly reduce the length of ICU stay and in-hospital stay of patients, which was of great significance for the reduction of medical costs and the long-term benefits of patients, thereby reducing the burden on society and individuals.

Renal Replacement Therapy in Critically Ill: Current Trend and New Direction

Critically ill patients often present with renal dysfunction. Acute kidney injury (AKI) is common in intensive care unit (ICU) patients and is often a component of multiple organ dysfunction syndrome (MODS). Renal replacement therapy (RRT) plays a significant role in management of acute and chronic renal failure in ICU. During the last decade RRT has made remarkable progress in management of renal dysfunction of critically ill. The Acute Dialysis Quality Initiative conceived in 2002 proposed RIFLE classification for AKI (risk, injury, failure, loss, end-stage kidney disease) using serum creatinine and urine output in critically ill patients. More recently, the Acute Kidney Injury Network (AKIN) has been introduced for staging AKI. Studies have shown that mortality increases proportionately with increasing severity of AKI. In patients with severe AKI requiring RRT mortality is approximately 50% to 70% according to one study and even a small changes in serum creatinine are associated with increased mortality. The most common causes of AKI in ICU are sepsis, hypovolemia, low cardiac output and drugs. The various techniques of RRT used in ICU include intermittent hemodialysis (IHD), continuous RRT (CRRT), sustained low efficiency dialysis (SLED) and peritoneal dialysis (PD). It is preferable to use RRT at either RIFLE injury type or at AKIN stage II in critically ill patients. IHD is commonly used in hemodynamically stable ICU patients. Because of high dialysate (500ml/min) IHD may cause hypotension in some patients. Solute removal may be episodic and often result in inferior uraemic control and acid base control. CRRT is usually initiated with a blood flow of 100 to 200 ml/min. and thus hemodynamic instability associated with IHD is avoided. Major advantages of CRRT include continuous control of fluid status, hemodynamic stability and control of acid base status. It is expensive and there is high risk of bleeding because of use of high dose of IV heparin. SLED has been found to be safe and effective in critically ill patients with hemodynamic instability. It uses the same dialysis machine of IHD and combines the effectiveness of CRRT in unstable patients and easy operability of IHD. It is also cost effective. PD is initiated in ICU for AKI patients when bedside IHD is not available. It is good for hemodynamically unstable patients when IHD or CRRT is difficult. In patients on mechanical ventilator, PD interferes with function of diaphragm causing decrease in lung compliance. Early identification of AKI with bio markers is an important step in improving outcomes of AKI. These bio markers help early detection of AKI before the onset of rise in serum creatinine. Serum cystatin C is one of the sensitive bio markers of small changes in Glomerular filtration rate (GFR) and has been found to be useful. AKI in the ICU most commonly results from multiple insults. Therefore appropriate and early identification of patients at risk of AKI provides an opportunity to prevent subsequent renal insults. This strategy will influence overall ICU morbidity and mortality.Bangladesh Crit Care J March 2015; 3 (1): 17-21

Evaluation of severity scoring systems in ICUs—translation, conversion and definition ambiguities as a source of inter-observer variability in Apache II, SAPS and OSF

To explore translation, conversion and definition ambiguities, when using severity scoring systems in patients admitted to intensive care units (ICUs). A prospective study of the prognosis of acute renal failure in ICUs. The study was conducted in 20 French ICUs. 360 patients presenting with severe acute renal failure were studied during their ICU stay. The inter-observer variability of Apache II (acute physiology and chronic health evaluation), SAPS (simplified acute physiology score), and OSF (organ-system failure) was considered. For Apache II, we explored the uncertainty of measurements arising from conversion into SI units, the rounding procedures used for the non-inclusive intervals defined for quantitative parameters such as age, mean arterial pressure (MAP) or serum creatinine, the absence of definition of acute renal failure (ARF) and its consequence on doubling serum creatinine values, and the absence of guidelines in the case of spontaneous ventilation when arterial blood gases (ABG) and forced inspiratory oxygen (FIO2) were not measured. The resulting variability was evaluated, calculating the lowest and the highest value of the scoring system for each patient. The mean difference by patient was greater than 1.5 (p < 0.0001). Other examples were presented and discussed for SAPS and OSF. Translation, conversion and definition ambiguities are a source of inter-observer variability and increase the risk of classification and/or selection biases. This gives rise to particular concern in the design and analysis of multicenter trials of meta-analysis, and improvement of these scoring systems should be envisaged in the future.