Renal Replacement Therapy Techniques Research Articles

Prevalencia de pacientes con tratamiento sustitutivo renal en El Salvador en 2014

El Salvador has the highest renal failure mortality rate in the Americas. Five healthcare providers offer renal replacement therapy (RRT) in the country. The national RRT prevalence has never been reported. AimsTo determine the RRT prevalence in El Salvador and some basic characteristics. MethodsThe association of nephrology coordinated a nationwide cross-sectional survey during the third quarter of 2014. 31 renal centres participated in the survey, covering 99.5% of patients. ResultsNational RRT prevalence: 595 per million population (pmp), N=3807, average age 50.4 years, 67.5% male. By modality: peritoneal dialysis (PD) 289 pmp, haemodialysis (HD) 233 pmp, with functioning kidney transplantation 74 pmp (living donor only). Social security covers 25% of the population but treats 49.7% of RRT patients. Generally, higher prevalence was observed in municipalities with renal centres or located on the coast or lowlands. Ninety-five percent of HD patients receive fewer than 3 weekly sessions. Of PD patients, 59% do not belong to a continuous outpatient or automated programme, and 25% still use rigid catheter. Aetiology of chronic kidney disease: unavailable/undetermined 50%, hypertension 21.1%, diabetes 18.9%, glomerulonephritis 6.7%, obstructive causes 1.2%, tubulointerstitial 0.9%, polycystic 0.4% and other 0.7%. DiscussionDespite the increase in RRT services, the prevalence is lower than the Latin American average (660 pmp). Three quarters of HD and PD patients are under-dialysed. Obsolete RRT techniques are still used. The presence of Mesoamerican nephropathy influences the demographic characteristics (many young patients, two-thirds male, high prevalence in lowlands and coastlands).

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

Gestion d’un traitement ablatif par l’iode 131 d’un carcinome thyroïdien chez un patient hémodialysé chronique

Iodine-131 ablation therapy for thyroid cancer in the patient on chronic hemodialysis represents a real problem since the main route of elimination of radioiodine is urinary. There is no recommendation on the management of this treatment in the patient on hemodialysis. We report our experience of management of this treatment in a patient aged 38 years, undergoing hemodialysis for chronic renal failure, and who have been indicated the treatment with iodine-131 for papillary thyroid carcinoma high risk. After multidisciplinary discussions (nephrologists and specialists in nuclear medicine and radiation safety), it has been decided to treat the patient with continuous ambulatory peritoneal dialysis therapy (CAPD). Because of the low but continuous elimination of iodine in the case of CAPD, the patient received a reduced ablative 131I dose of 1850MBq, which is 30% of the usual dose delivered in subjects with normal renal function. The patient was hospitalized for four days in nuclear medicine unit and the 131I radioactivity emitted from him was 2.5μSv/h at one meter at his hospital discharge. In conclusion, CAPD in relay of hemodialysis is a technique of renal replacement therapy that can be suggested to minimize exposure to radioactivity to the patient, his family and the medical staff.

Utilización de las terapias de depuración extracorpórea en los Servicios de Medicina Intensiva de Cataluña (España)

ObjectiveTo assess the indications, settings and techniques used in renal replacement therapy (RRT) in Intensive Care Units (ICUs). Study designA prospective, multicenter observational study was carried out. SettingIntensive Care Units. PatientsAll patients admitted to ICUs during the two-month study period in 2011 who required RRT. InterventionsNone. Variables of interestPatient demographic characteristics, baseline clinical data, RRT technique and materials used. ResultsThirty-three patients were analyzed. RRT was started within the first 24hours after ICU admission in 17 of the 33 patients (52%). At the start of RRT, 18% of the patients (n=6) presented grade R on the RIFLE acute kidney injury (AKI) scale. The most common disorder associated with AKI was multiple organ dysfunction syndrome (64%; n=21). At the start of RRT, most patients (76%; n=25) presented hemodynamic instability, while the remaining 24% (n=8) were considered hemodynamically stable. The most common RRT technique in hemodynamically stable patients was continuous renal replacement therapy (CRRT) (63%; n=5). CRRT was the technique of choice in all 25 of the hemodynamically unstable patients (100%). Anticoagulation was used in 55% (n=18) of the patients. In most cases (61%, n=20), RRT was administered through the right femoral vein. In 84% (n=28) of the patients, the ultrafiltration effluent flow rate was ≤ 35ml/kg/h. ConclusionsThe ICU physicians in this study followed current RRT guidelines. CRRT was preferred over intermittent renal replacement therapy, regardless of patient hemodynamic status.

Continuous renal replacement therapy during extracorporeal membrane oxygenation in patients treated in medical intensive care unit: technical considerations.

Extracorporeal membrane oxygenation (ECMO) is used as a salvage therapy in refractory acute respiratory distress syndrome (ARDS). Although technological progress in the ECMO systems improved the survival rate, prognosis is still significantly worsened by acute kidney injury (AKI), particularly if renal replacement therapy (RRT) is required. There are no exact guidelines recommending which techniques of ECMO and continuous RRT (CRRT) should be used for management of AKI coexisting with respiratory or circulatory failure, and how to combine them. The aim of this review is to describe methods of CRRT and ECMO simultaneous application, and to present advantages of various technical approaches versus possible complications.

PERITONEAL DIALYSIS: CAUSES OF INADEQUACY OF THE TECHNIQUE

In recent years peritoneal dialysis is gaining an increasing prevalence in the treatment of patients with chronic stage V kidney disease. The possibility of long–term use of this technique of renal replacement therapy remains limited. This article provides insight onto possible causes of peritoneal dialysis failure in patients with terminal renal insufficiency.

Thirty years in a peritoneal dialysis unit: long-term survival.

Peritoneal dialysis (PD) is an established renal replacement therapy technique which thanks to the technological and clinical advances has improved its survival rates in recent years. The aim of this study was to evaluate patient and technique survival in PD over 30 years, according to the different decades in order to consolidate its usefulness in healthcare. Retrospective cohort study including all patients in the PD programme of the Hospital Universitario La Paz (Madrid), from 1980 to 2010. Demographic and clinical variables were collected from medical records. A total of 667 patients were included, 54.4% male, with a mean age of 51.47 years and a median follow-up period of 23.1 months. There was a progressive increase in PD incident patients, especially in automated PD (APD). Patient survival at 5 years was 54%, with a median of 64.66 months, increasing significantly in the last decade (P=.000). Age, comorbidity, male sex, chronic ambulatory PD (CAPD) and diabetes were predictors of patient survival. Technique survival at 5 years was 64.2% with a median of 82 months. The success of the technique was greater in younger patients on APD and with lower comorbidity. Over 30 years, we found an increase in incident patients. Age, comorbidity and diabetes still continue to be the main determining factors for survival.

Management of renal replacement therapy in ICU patients: an international survey

The optimal management of renal replacement therapy (RRT) in critically ill patients remains a matter of debate, although insights have arisen from recent large trials. Nonetheless, little is known about the current practices and beliefs of intensivists. The goal of this study was to record current practices in RRT management among an international panel of intensivists. An online questionnaire that included questions about RRT management in critically ill patients with acute kidney injury was sent to European Society of Intensive Care Medicine members in 2010. Two hundred and seventy-three intensivists from 50 countries responded. The respondents had an average of 12 (7-20) years of experience in ICUs, and most of them worked in mixed ICUs. Most of the intensivists were responsible for prescribing RRT (92.6 %). Half of the respondents reported using both intermittent haemodialysis and continuous renal replacement therapy techniques (CRRT), but most preferred using CRRT. The reasons for preferring CRRT were the perception of better haemodynamic stability, better therapeutic effect resulting from cytokine removal and easier fluid balance control. The intensivists used higher RRT doses in septic patients than in non-septic patients (p = 0.03). Finally, we observed an increasing inclination towards the early use of RRT among the intensivists. CRRT remains the preferred technique for most intensivists in Europe, and a large proportion of the participating intensivists used RRT prescription doses similar to those proposed a decade ago. Our results provide insights into the motivations of intensivists while presenting the technique that may help in selecting control groups for future trials.

Long‐term outcome after acute renal replacement therapy: a narrative review

Acute kidney injury (AKI) necessitating renal replacement therapy (RRT) is associated with high short-term mortality, relatively little however is known of the long-term outcome in these patients. This narrative review describes renal recovery, long-term mortality, and quality of life in RRT patients with acute kidney injury. A literature search using the PubMed search engine from the year 2000 to present with the MeSH terms 1) acute kidney injury, renal replacement therapy, prognosis, and 2) acute kidney injury, quality of life, prognosis, was performed, including studies addressing long-term outcome (over 60 days) in adults with AKI on RRT. According to inclusion criteria, twenty two studies were eligible. Outcome varied depending on AKI aetiology, setting, co-morbidity and pre-morbid renal function. Five-year-survival was between 15% and 35%, with dialysis dependence in less than 10% of survivors. Renal recovery, even if incomplete occurred during the first year. Quality of life assessment amongst survivors indicated moderate physical impairment and reduced mental health scores. A majority of patients returned to employment and self-sustainability and reported acceptable to good quality of life. Over 90% of patients indicated that they would undergo the same treatment again. Early initiation of treatment and fine-tuning of the RRT technique may improve outcome. Consensus regarding AKI definitions, renal function measurement and standardised follow-up regimens are required. Further long-term studies are needed.

Antifungal Dose Adjustment in Renal and Hepatic Dysfunction: Pharmacokinetic and Pharmacodynamic Considerations

Adjusting the dose of antifungal agents for renal and hepatic impairment can be challenging given that clinicians must rely on limited pharmacokinetic data to derive specific regimens. These pharmacokinetic studies are typically performed in a small number of patients without invasive fungal infection, and results are not often reported in concert with accepted pharmacodynamic indices. This article aims to review pertinent pharmacokinetic studies of antifungal drugs in patients with renal or hepatic dysfunction. The impact of novel continuous renal replacement therapy techniques on the pharmacokinetic disposition of antifungal agents will also be described where data are available. Subsequently, this review provides recommendations for antifungal drug dosing in patients with kidney or liver dysfunction after accounting for established or emerging pharmacokinetic-pharmacodynamic relationships as they relate to antifungal drug efficacy in vivo.

Fármacos y diálisis

Renal replacement therapy (RRT) techniques are increasingly being used in severely ill patients and complex clinical situations. In some circumstances, these patients must be administered potent drugs with a narrow therapeutic margin in which pharmacokinetic modifications can lead to a lack of efficacy or toxicity. Knowledge of which drugs undergo pharmacokinetic modification when used in patients under RRT is essential and therapeutic monitoring of plasma concentrations is needed for dosage adjustment. The drug characteristics to be considered are molecular weight, binding to plasma proteins, hydrophilicity, lipophilicity, and volume of distribution. Drug clearance in RRT depends on the type of extraction performed (diffusion or convection), as well as on adsorption and adhesion to the semipermeable membrane used. The efficiency of different techniques in drug extraction, in decreasing order, is as follows: continuos veno-venous hemodiafiltration, continuos veno-venous hemofiltration and intermittent hemodialysis. To perform dosage adjustment of antimicrobials, pharmacokinetics/pharmacodynamics relationships must be considered. When the bactericidal effect is concentration-dependent, the dose must be maintained or increased at each administration and, if necessary, the interval between administrations must be extended. When the bactericidal effect is time-dependent, the interval between doses may need to be shortened instead of increasing the dose at each administration. There are insufficient clinical studies to allow precise definition of the doses to be administered. Schedules that serve as a guide are available but doses must be individually tailored depending on the drug, the clinical situation and the RRT technique used.

Pharmacokinetics of antibiotics or antifungal drugs in intensive care units

Intensive care unit (ICU) patients present several unusual pharmacokinetic (PK) characteristics compared with less seriously ill patients, including increased distribution volume and variable clearance. Interpatient PK variability is often considerable and can produce a wide range of values for PK parameters and major differences in drug exposure. These analyses have led to the development of simulation techniques and population PK models to assess dosing regimens in specific patient subsets. Plasma concentrations may frequently overestimate target-site concentrations and therefore clinical efficacy. The unbound drug concentration at the infection site should be preferred. Although renal replacement therapy techniques are commonly used in ICU patients, data concerning antibiotic dosing in this setting remain limited. Administration of antibacterial agents by continuous infusion is becoming a common technique to avoid undesirable high peak concentrations and low trough concentrations and to optimize PK-pharmacodynamic indices.

Patient and Kidney Survival by Dialysis Modality in Critically Ill Patients with Acute Kidney Injury

Using a large, international cohort, we sought to determine the effect of initial technique of renal replacement therapy (RRT) on the outcome of acute renal failure (ARF) in the intensive care unit (ICU). We enrolled 1218 patients treated with continuous RRT (CRRT) or intermittent RRT (IRRT) for ARF in 54 ICUs in 23 countries. We obtained demographic, biochemical and clinical data and followed patients to either death or hospital discharge. Information was analyzed to assess the independent impact of treatment choice on survival and renal recovery. Patients treated first with CRRT (N=1006, 82.6%) required vasopressor drugs and mechanical ventilation more frequently compared to those receiving IRRT (N=212, 17.4%), (p<0.0001). Unadjusted hospital survival was lower (35.8% vs. 51.9%, p<0.0001). However, unadjusted dialysis-independence at hospital discharge was higher after CRRT (85.5% vs. 66.2%, p<0.0001). Multivariable logistic regression showed that choice of CRRT was not an independent predictor of hospital survival or dialysis-free hospital survival. However, the choice of CRRT was a predictor of dialysis independence at hospital discharge among survivors (OR: 3.333, 95% CI: 1.845 - 6.024, p<0.0001). Further adjustment using a propensity score did not significantly change these results. We conclude that worldwide, the choice of CRRT as initial therapy is not a predictor of hospital survival or dialysis-free hospital survival but is an independent predictor of renal recovery among survivors.

Clinical effects of online dialysate and infusion fluids

Online hemodiafiltration appears to be the most effective technique of renal replacement therapy in many respects. Removal of small and high-molecular weight substances is enhanced. Modern technology ensures a safe, online production of reinfusion fluids. Nonetheless, stringent maintenance rules are required for the production of sterile and nonpyrogenic-dialysate solutions. In this review, we will critically review the state of the art of the clinical effects derived from the use of ultrapure dialysate and the online production of dialysate fluids in high-flux hemodiafiltration.

Practice patterns in the management of acute renal failure in the critically ill patient: an international survey

Several controversies have developed over acute renal failure (ARF) definition and treatment: which approach to patient care is most desirable and which form of renal replacement therapy (RRT) should be applied is an everyday matter of debate. There is also disagreement on clinical practice for RRT including the best timing to start, vascular access, anti-coagulation, membranes, equipment and finally, if continuous or intermittent techniques should be preferred. In this lack of harmony, the epidemiology of ARF has recently displayed an outbreak of cases in the intensive care units and nephrologists and intensivists are now called to work together in the case of such a syndrome. We report on the responses of 560 contributors, mostly coming from Europe, to a questionnaire submitted during the third International Course on Critical Care Nephrology held in Vicenza, Italy in June 2004. The questionnaire was divided into several sections concerning demographic and medical information, definition of ARF, practice of RRT, current opinions about clinical advantages and problems related to different RRTs and modalities, and beliefs on alternative indications to extracorporeal treatments. More then 200 different definitions of ARF and about 90 RRT start criteria were reported. Oliguria and RIFLE (an acronym classifying ARF in different levels of severity: Risk of renal dysfunction; Injury to the kidney; Failure of kidney function; Loss of kidney function; End-stage kidney disease.) were the most frequent criteria used to define ARF. In 10% of centres all forms of renal replacement techniques are available, and in 70% of cases two or more different techniques are available: absolute analysis of different techniques showed that continuous renal replacement therapies are utilized by 511 specialists (91%), intermittent haemodialysis by 387 (69%) and sustained low efficiency dialysis by 136 (24%). Treatment prescription showed significant differences among specialists, 60% of intensivists being uncertain on RRT dose prescription compared to 40% of nephrologists (P = 0.002). The most frequently selected dosage was '35 ml/kg/h' for urea (25%) and creatinine targets (26%), and '2-3 l/h' for the septic dose (25%). Of the participants, 90% said that they used RRT for non-renal indications, 60% although responders admitted the lack of scientific evidence as a limiting factor to its use. New classifications such as RIFLE criteria might improve well-known uncertainty about ARF definition. Different RRT techniques are available in most centres, but a general lack of treatment dose standardization is noted by our survey. Non-renal indications to RRT still need to find a definitive role in routine practice.

Controversies and Issues in Hemodiafiltration Therapy

Hemodiafiltration appears to be the most effective technique of renal replacement therapy but several drawbacks are not counterbalanced by significant advantages. Although optimal transfer for both small and middle molecules can be achieved, there is no difference in mortality risk between HDF and HD patients. The infusion of a large amount of dialysate containing residual acetate of 2–7 mmol/l could lead to impaired cardiac contractile functions and carbonyl stress whereas loss of amino acids and water-soluble vitamins along with high UF rate could lead to malnutrition. Moreover, as substitution fluid is prepared on-line, contaminated fluid could be inadvertently infused to patients. Stringent maintenance rules are required for the production of sterile and non-pyrogenic dialysis solutions. Finally, daily hemodialysis could be the most promising mode of renal replacement therapy since it leads to a more stable ‘milieu interieur’ than other techniques whatever the mode of solutes removal when performed three times a week.

Causes and Prognosis of Nontraumatic Acute Renal Failure Requiring Dialysis in Adult Patients with and without Diabetes

Despite advanced techniques of renal replacement therapy the overall mortality of patients with ARF is still high. The majority of patients with ARF requiring dialysis are those with nontraumatic ARF. In a retrospective study we compared the causes of nontraumatic ARF, the risk factors for the development of renal failure and the mortality rates in patients with and without diabetes mellitus who received dialysis therapy in the years 1991–2000. A total of 232 patients were included in the study, 34 (14.6%) of them with and 198 patients (85.4%) without diabetes. The predominant causes of nontraumatic ARF like congestive heart failure (26.4 vs. 13.6, p < 0.05) and hypotension/hypovolemia (20.6 vs. 7.6%, p < 0.05) occurred more frequently in diabetic patients. The prevalence of sepsis (8.8 vs. 10.1%, NS), malignancy/hypercalcemia (5.8 vs. 11.6%, NS) and other causes of nontraumatic ARF were similar in both groups. The prevalence of hepato‐renal syndrome (5.8 vs. 13.6%, p < 0.05) and acute kidney graft failure (2.9 vs. 15.1%, p < 0.05) was higher in the nondiabetic individuals. Patients with diabetes showed more often chronic predictors for the onset of ARF like pre‐existing hypertension (93.6 vs. 51.0%, p < 0.05), congestive heart failure (44.1 vs. 14.6%, p < 0.005), pre‐existing renal insufficiency (76.4 vs. 46.9%, p < 0.05) and ACE‐inhibitor therapy (32.3 vs. 9.6%, p < 0.005). Additionally, the prevalence of multiple organ failure (MOF) as prognostic factor was significantly higher in the diabetic patients (47.0 vs. 21.7%, p < 0.05). The mean number of dialyses therapy was 4.7 vs. 4.5 per patient. The overall mortality was 41.1 vs. 44.% (NS). In conclusion, the prevalence of the most common causes of nontraumatic ARF was different between the patients with and without diabetes. The diabetic individuals had more frequently predictors for the onset of ARF. The overall mortality was approximately the same in both groups.

Plasmapheresis in sepsis

Despite the impressive advances in our understanding of the basic mechanisms of sepsis, mortality associated with sepsis remains high. Some experimental and clinical evidence suggests that hemofiltration or other techniques commonly used in the continuous renal replacement therapies are able to remove sepsis mediators, although the precise mechanism responsible (filtration or adsorption) can differ according to the membrane used. It has not yet been convincingly demonstrated, however, that this effect can influence the outcome. In recent years, plasma processing techniques such as plasma exchange and plasmapheresis have been increasingly used with the aim of removing septic mediators. Albeit slightly more complicated than the commonly used continuous renal replacement therapy techniques, these procedures allow the removal of substances with higher molecular weight, and, with the more sophisticated devices, the plasma processed can be reinfused instead of discarded, thus reducing the need for replacement fluid. Even if these treatments have been associated with an overall improvement of sepsis-induced pathophysiologic derangements, more experience is needed to establish their effect on the outcome of septic patients.

CONTINUOUS ARTERIOVENOUS HEMODIAFILTRATION IN THE ACUTE TREATMENT OF HYPERAMMONAEMIA DUE TO ORNITHINE TRANSCARBAMYLASE DEFICIENCY

Background. Acute hyperammonemia caused by urea cycle disorder is a medical emergency for which immediate managements should be taken to minimize permanent brain damage. Among different enzyme defects, ornithine transcarbamylase deficiency (OTC) is one of the most common enzyme defect in urea cycle disorders. We utilized continuous renal replacement therapy techniques in the acute treatment of hyperammonemia due to ornithine transcarbamylase deficiency.Patients and methods. Three male neonates with elevated serum ammonia levels were shown, based on urine organic acid analysis and serum amino acid studies, to have OTC deficiency. Administration of sodium benzoate and sodium phenylacetate for activating alternative nitrogen waste pathway were used associated with protein restriction. Other modalities, including blood exchange transfusion, peritoneal dialysis, continuous renal replacement therapy were utilized in an attempt to lower serum ammonia concentration.Results. We report the successful use of continuous arteriovenous hemofiltration (CAVH), continuous arteriovenous hemodialysis (CAVHD), continuous arteriovenous hemodiafiltration (CAVHDF) in the acute management of hyperammonemia due to OTC deficiency. We also compared the ammonia clearance between peritoneal dialysis, exchange transfusion, CAVH, CAVHD and CAVHDF. It demonstrated the evidence that CAVHDF provides the best ammonia clearance.Conclusion. Continuous renal replacement therapy including CAVH, CAVHD, and CAVHDF may be the alternative techniques for acute management of hyperammonemia in inborn error of metabolism when dialysis machine is not available. Our data suggests CAVHDF provides the best ammonia clearance.

Continuous venovenous hemodiafiltration in infants and children

Continuous venovenous hemodiafiltration (CVVHD) is not commonly used in pediatric intensive care units due to the lack of suitable equipment needed for this technique of renal replacement therapy (RRT). We have used an adapted hemodialysis machine that includes a blood pump controller, an air leak detector, and a venous pressure monitor over the past year in the pediatric intensive care unit. Blood lines available for hemodialysis were used for CVVHD, limiting the extracorporeal circuit volume to 38 mL, which allows for CVVHD capability in an infant as small as 4.5 kg without a blood-primed circuit. We have compared this experience to previous continuous arteriovenous hemodiafiltration (CAVHD) at our institution. The two groups (CVVHD and CAVHD) were similar in age, weight, blood pressure, and indication for RRT. There was significantly less number of hemofilters used, an improved number of hours per hemofilter, and a significantly less change of RRT modality due to ineffective dialysis (CVVHD 0% v CAVHD 32%) when using CVVHD. Furthermore, an average of 48% less heparin was used in the CVVHD population. We conclude that CVVHD can be safely and effectively carried out in infants and small children with less heparinization, no need for arterial access, and less risk of ineffective RRT.