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Kulkarni M, Prabhu AR, Rao IR, Nagaraju SP. Interventions for preventing haemodialysis dysequilibrium syndrome. Cochrane Database Syst Rev 2024; 5:CD015526. [PMID: 38775299 PMCID: PMC11110491 DOI: 10.1002/14651858.cd015526.pub2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/25/2024]
Abstract
BACKGROUND Dialysis dysequilibrium syndrome (DDS) refers to neurological symptoms usually seen during or after new initiation or following reinitiation of haemodialysis (HD) after missing multiple sessions. DDS is associated with death and morbidity. We studied interventions aimed at preventing DDS. OBJECTIVES To evaluate the benefits and harms of different types of interventions for preventing DDS. SEARCH METHODS We contacted the information specialist and searched the Cochrane Kidney and Transplant Register of Studies up to 8 May 2024 using search terms relevant to this review. Studies in the Register were identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Registry Platform (ICTRP) Search Portal, and ClinicalTrials.gov. SELECTION CRITERIA We included randomised controlled trials (RCTs) that compared any intervention against standard care, including individuals initiated on HD, regardless of age. DATA COLLECTION AND ANALYSIS Two authors independently determined study eligibility, assessed quality and extracted data. Data were collected on methods, interventions, participants, and outcomes (DDS incidence, severe DDS, death, adverse events). Risk ratios (RR) and confidence intervals (CI) were calculated. Study quality was assessed using the Cochrane Risk of Bias 2 (ROB2) tool. Confidence in the evidence was assessed using the Grading of Recommendations Assessment, Development and Evaluation (GRADE) approach. MAIN RESULTS We included two RCTs, enrolling 32 adult participants. Interventions included were slow dialysis, sodium modelling, standard sodium dialysate, and high sodium dialysate. The risk of bias was of some concern to high risk of bias in both studies. Slow dialysis compared to sodium modelling (1 study, 15 participants) may result in little to no difference in DDS, severe DDS, and death (low certainty evidence) and has uncertain effects on adverse events (RR 1.33, 95% CI 0.15 to 11.64; very low certainty evidence). Standard sodium dialysate compared to high sodium dialysate (1 study, 17 participants) has uncertain effects on the incidence of DDS (RR 0.07, 95% CI 0.00 to 1.12), severe DDS (RR 0.47, 95% CI 0.02 to 10.32), and adverse events (RR 0.29, 95% CI 0.08 to 1.02) (very low certainty evidence). AUTHORS' CONCLUSIONS In HD patients, sodium modelling, compared to slow dialysis, may result in little to no difference in DDS and death (low certainty evidence) and has uncertain effects on adverse events (very low certainty evidence). The evidence is very uncertain for the effect of high-sodium dialysate and standard sodium dialysate on DDS, death and adverse events (very low certainty evidence).
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Affiliation(s)
- Manjunath Kulkarni
- Department of Nephrology, Father Muller Medical College, Mangaluru, India
| | - Attur Ravindra Prabhu
- Department of Nephrology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Indu Ramachandra Rao
- Department of Nephrology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, India
| | - Shankar Prasad Nagaraju
- Department of Nephrology, Kasturba Medical College Manipal, Manipal Academy of Higher Education, Manipal, India
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Fayad AI, Buamscha DG, Ciapponi A. Timing of kidney replacement therapy initiation for acute kidney injury. Cochrane Database Syst Rev 2022; 11:CD010612. [PMID: 36416787 PMCID: PMC9683115 DOI: 10.1002/14651858.cd010612.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common condition among patients in intensive care units (ICUs) and is associated with high numbers of deaths. Kidney replacement therapy (KRT) is a blood purification technique used to treat the most severe forms of AKI. The optimal time to initiate KRT so as to improve clinical outcomes remains uncertain. This is an update of a review first published in 2018. This review complements another Cochrane review by the same authors: Intensity of continuous renal replacement therapy for acute kidney injury. OBJECTIVES To assess the effects of different timing (early and standard) of KRT initiation on death and recovery of kidney function in critically ill patients with AKI. SEARCH METHODS We searched the Cochrane Kidney and Transplant's Specialised Register to 4 August 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register, ClinicalTrials and LILACS to 1 August 2022. SELECTION CRITERIA We included all randomised controlled trials (RCTs). We included all patients with AKI in the ICU regardless of age, comparing early versus standard KRT initiation. For safety and cost outcomes, we planned to include cohort studies and non-RCTs. DATA COLLECTION AND ANALYSIS Data were extracted independently by two authors. The random-effects model was used, and results were reported as risk ratios(RR) for dichotomous outcomes and mean difference(MD) for continuous outcomes, with 95% confidence intervals (CI). MAIN RESULTS We included 12 studies enrolling 4880 participants. Overall, most domains were assessed as being at low or unclear risk of bias. Compared to standard treatment, early KRT initiation may have little to no difference on the risk of death at day 30 (12 studies, 4826 participants: RR 0.97,95% CI 0.87 to 1.09; I²= 29%; low certainty evidence), and death after 30 days (7 studies, 4534 participants: RR 0.99, 95% CI 0.92 to 1.07; I² = 6%; moderate certainty evidence). Early KRT initiation may make little or no difference to the risk of death or non-recovery of kidney function at 90 days (6 studies, 4011 participants: RR 0.91, 95% CI 0.74 to 1.11; I² = 66%; low certainty evidence); CIs included both benefits and harms. Low certainty evidence showed early KRT initiation may make little or no difference to the number of patients who were free from KRT (10 studies, 4717 participants: RR 1.07, 95% CI 0.94 to1.22; I² = 55%) and recovery of kidney function among survivors who were free from KRT after day 30 (10 studies, 2510 participants: RR 1.02, 95% CI 0.97 to 1.07; I² = 69%) compared to standard treatment. High certainty evidence showed early KRT initiation increased the risk of hypophosphataemia (1 study, 2927 participants: RR 1.80, 95% CI 1.33 to 2.44), hypotension (5 studies, 3864 participants: RR 1.54, 95% CI 1.29 to 1.85; I² = 0%), cardiac-rhythm disorder (6 studies, 4483 participants: RR 1.35, 95% CI 1.04 to 1.75; I² = 16%), and infection (5 studies, 4252 participants: RR 1.33, 95% CI 1.00 to 1.77; I² = 0%); however, it is uncertain whether early KRT initiation increases or reduces the number of patients who experienced any adverse events (5 studies, 3983 participants: RR 1.23, 95% CI 0.90 to 1.68; I² = 91%; very low certainty evidence). Moderate certainty evidence showed early KRT initiation probably reduces the number of days in hospital (7 studies, 4589 participants: MD-2.45 days, 95% CI -4.75 to -0.14; I² = 10%) and length of stay in ICU (5 studies, 4240 participants: MD -1.01 days, 95% CI -1.60 to -0.42; I² = 0%). AUTHORS' CONCLUSIONS Based on mainly low to moderate certainty of the evidence, early KRT has no beneficial effect on death and may increase the recovery of kidney function. Earlier KRT probably reduces the length of ICU and hospital stay but increases the risk of adverse events. Further adequate-powered RCTs using robust and validated tools that complement clinical judgement are needed to define the optimal time of KRT in critical patients with AKI in order to improve their outcomes. The surgical AKI population should be considered in future research.
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Affiliation(s)
- Alicia Isabel Fayad
- Pediatric Nephrology, Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina
| | - Daniel G Buamscha
- Pediatric Critical Care Unit, Juan Garrahan Children's Hospital, Buenos Aires, Argentina
| | - Agustín Ciapponi
- Argentine Cochrane Centre, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Buenos Aires, Argentina
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Valdenebro M, Martín-Rodríguez L, Tarragón B, Sánchez-Briales P, Portolés J. Renal replacement therapy in critically ill patients with acute kidney injury: 2020 nephrologist's perspective. Nefrologia 2021; 41:102-114. [PMID: 36166210 DOI: 10.1016/j.nefroe.2021.05.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 07/28/2020] [Indexed: 06/16/2023] Open
Abstract
Renal replacement therapies (RRT) as support for acute kidney injury in critically ill patients have become a routine and essential practice in their management, resulting in the widespread use of various techniques among these patients, such as intermittent hemodialysis (IHD), extended hemodialysis and continuous RRT (CRRT). In this review we aim to summarize current evidence of indication, choice of modality, timing of initiation, dosing and technical aspects of RRT. We carried out a narrative review based on guidelines, consensus documents by main working groups and the latest relevant clinical trials on RRT in the critically ill. We did not find enough evidence of any RRT modality having superior benefits in terms of patient survival, length of intensive care unit/hospital stay or renal outcomes among critically ill patients, in spite of optimization of clinical indication, modality, timing of initiation and intensity of initial therapy. This is still a controverted matter, since only early start of high-flux CRRT has been proven beneficial over IHD among hemodynamically unstable postoperative patients. Our objective is to portrait current RRT practices in multidisciplinary management of critically ill patients by intensive care and nephrology professionals. Implication of a nephrologist in the assessment of hemodynamic status, coexisting medical conditions, renal outcome expectations and management of resources could potentially have benefits at the time of RRT selection and troubleshooting.
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Affiliation(s)
- María Valdenebro
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; RedinRen RETIC ISCIII 16/009/009
| | - Leyre Martín-Rodríguez
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; RedinRen RETIC ISCIII 16/009/009
| | - Blanca Tarragón
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Paula Sánchez-Briales
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain
| | - Jose Portolés
- Servicio de Nefrología, Hospital Universitario Puerta de Hierro, Majadahonda, Madrid, Spain; RedinRen RETIC ISCIII 16/009/009.
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Lund A, Damholt MB, Wiis J, Kelsen J, Strange DG, Møller K. Intracranial pressure during hemodialysis in patients with acute brain injury. Acta Anaesthesiol Scand 2019; 63:493-499. [PMID: 30511386 DOI: 10.1111/aas.13298] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2018] [Revised: 09/30/2018] [Accepted: 10/23/2018] [Indexed: 11/30/2022]
Abstract
BACKGROUND Because osmotic fluid shifts may occur over the blood-brain barrier, patients with acute brain injury are theoretically at risk of surges in intracranial pressure (ICP) during hemodialysis. However, this remains poorly investigated. We studied changes in ICP during hemodialysis in such patients. METHODS We performed a retrospective study of patients with acute brain injury admitted to Rigshospitalet (Copenhagen, Denmark) from 2012 to 2016 who received intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT) while undergoing ICP monitoring. Data from each patient's first dialysis session were collected. Area under the curve divided by time (AUC/t) for ICP was calculated separately before and during dialysis. RESULTS Thirteen patients were included. During dialysis, ICP increased from a baseline of 11.9 mm Hg (median; interquartile range 6.3-14.7) to a maximum of 21 mm Hg (18-27) (P = 0.0024), and AUC/t for ICP was greater during dialysis (15.2 (13.4-18.8) vs 11.7 mm Hg (6.4-15.1), P = 0.042). The maximum ICP increase was independent of dialysis modality, but peak values were reached earlier in patients treated with IHD (N = 4) compared to CRRT (N = 9) (75 [30-90] vs 375 min [180-420] after start of treatment, P = 0.0095). The maximum ICP increase correlated positively to the baseline plasma urea concentration (Spearman's r = 0.69, P = 0.017). CONCLUSION Hemodialysis is associated with increased ICP in neurocritically ill patients, and the magnitude of the increase may be related to initial plasma urea levels.
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Affiliation(s)
- Anton Lund
- Department of Neuroanaesthesiology, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Mette B. Damholt
- Department of Nephrology, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Jørgen Wiis
- Department of Intensive Care, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Jesper Kelsen
- Department of Neurosurgery, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Ditte G. Strange
- Department of Neuroanaesthesiology, Rigshospitalet University of Copenhagen Copenhagen Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, Rigshospitalet University of Copenhagen Copenhagen Denmark
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Fayad AII, Buamscha DG, Ciapponi A. Timing of renal replacement therapy initiation for acute kidney injury. Cochrane Database Syst Rev 2018; 12:CD010612. [PMID: 30560582 PMCID: PMC6517263 DOI: 10.1002/14651858.cd010612.pub2] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common condition among patients in intensive care units (ICUs), and is associated with high death. Renal replacement therapy (RRT) is a blood purification technique used to treat the most severe forms of AKI. The optimal time to initiate RRT so as to improve clinical outcomes remains uncertain.This review complements another Cochrane review by the same authors: Intensity of continuous renal replacement therapy for acute kidney injury. OBJECTIVES To assess the effects of different timing (early and standard) of RRT initiation on death and recovery of kidney function in critically ill patients with AKI. SEARCH METHODS We searched the Cochrane Kidney and Transplant's Specialised Register to 23 August 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched LILACS to 11 September 2017. SELECTION CRITERIA We included all randomised controlled trials (RCTs). We included all patients with AKI in ICU regardless of age, comparing early versus standard RRT initiation. For safety and cost outcomes we planned to include cohort studies and non-RCTs. DATA COLLECTION AND ANALYSIS Data were extracted independently by two authors. The random-effects model was used and results were reported as risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI). MAIN RESULTS We included five studies enrolling 1084 participants. Overall, most domains were assessed as being at low or unclear risk of bias. Compared to standard treatment, early initiation may reduce the risk of death at day 30, although the 95% CI does not rule out an increased risk (5 studies, 1084 participants: RR 0.83, 95% CI 0.61 to 1.13; I2 = 52%; low certainty evidence); and probably reduces the death after 30 days post randomisation (4 studies, 1056 participants: RR 0.92, 95% CI 0.76 to 1.10; I2= 29%; moderate certainty evidence); however in both results the CIs included a reduction and an increase of death. Earlier start may reduce the risk of death or non-recovery kidney function (5 studies, 1076 participants: RR 0.83, 95% CI 0.66 to 1.05; I2= 54%; low certainty evidence). Early strategy may increase the number of patients who were free of RRT after RRT discontinuation (5 studies, 1084 participants: RR 1.13, 95% CI 0.91 to 1.40; I2= 58%; low certainty evidence) and probably slightly increases the recovery of kidney function among survivors who discontinued RRT after day 30 (5 studies, 572 participants: RR 1.03, 95% CI 1.00 to 1.06; I2= 0%; moderate certainty evidence) compared to standard; however the lower limit of CI includes the null effect. Early RRT initiation increased the number of patients who experienced adverse events (4 studies, 899 participants: RR 1.10, 95% CI 1.03 to 1.16; I2 = 0%; high certainty evidence). Compared to standard, earlier RRT start may reduce the number of days in ICU (4 studies, 1056 participants: MD -1.78 days, 95% CI -3.70 to 0.13; I2 = 90%; low certainty evidence), but the CI included benefit and harm. AUTHORS' CONCLUSIONS Based mainly on low quality of evidence identified, early RRT may reduce the risk of death and may improve the recovery of kidney function in critically patients with AKI, however the 95% CI indicates that early RRT might worsen these outcomes. There was an increased risk of adverse events with early RRT. Further adequate-powered RCTs using appropriate criteria to define the optimal time of RRT are needed to reduce the imprecision of the results.
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Affiliation(s)
- Alicia Isabel I Fayad
- Ricardo Gutierrez Children's HospitalPediatric NephrologyInstitute for Clinical Effectiveness and Health PolicyLos Incas Av 4174Buenos AiresArgentina1427
| | - Daniel G Buamscha
- Juan Garrahan Children's HospitalPediatric Critical Care UnitCombate de Los Pozoz Y PichinchaBuenos AiresArgentina
| | - Agustín Ciapponi
- Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET)Argentine Cochrane CentreDr. Emilio Ravignani 2024Buenos AiresArgentinaC1414CPV
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Niemi MA, Stoff JS. COUNTERPOINT: Should Continuous Venovenous Hemofiltration Always Be the Preferred Mode of Renal Replacement Therapy for the Patient With Acute Brain Injury? No. Chest 2017; 152:1111-1114. [DOI: 10.1016/j.chest.2017.08.1158] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/23/2017] [Accepted: 08/23/2017] [Indexed: 11/28/2022] Open
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Hamdi T, Yessayan L, Yee J, Szamosfalvi B. High sodium continuous veno-venous hemodialysis with regional citrate anticoagulation and online dialysate generation in patients with acute liver failure and cerebral edema. Hemodial Int 2017; 22:184-191. [DOI: 10.1111/hdi.12572] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Affiliation(s)
- Tamim Hamdi
- Department of Internal Medicine, Division of Nephrology; UT Southwestern; Dallas TX USA
| | - Lenar Yessayan
- Department of Internal Medicine, Division of Nephrology; University of Michigan; Ann Arbor MI USA
| | - Jerry Yee
- Department of Internal Medicine, Division of Nephrology; Henry Ford Hospital; Detroit MI USA
| | - Balazs Szamosfalvi
- Department of Internal Medicine, Division of Nephrology; University of Michigan; Ann Arbor MI USA
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Medow JE, Sanghvi SR, Hofmann RM. Use of High-Flow Continuous Renal Replacement Therapy with Citrate Anticoagulation to Control Intracranial Pressure by Maintaining Hypernatremia in a Patient with Acute Brain Injury and Renal Failure. Clin Med Res 2015; 13:89-93. [PMID: 25487240 PMCID: PMC4504660 DOI: 10.3121/cmr.2014.1238] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2014] [Accepted: 08/13/2014] [Indexed: 12/13/2022]
Abstract
Traumatic brain injury and intracranial hypertension often require treatment to optimize patient outcome. There are a variety of complex medical conditions that can preclude standard approaches to the treatment of intracranial hypertension. We describe a case where a novel approach using continuous dialysis with trisodium citrate was used to optimize the outcome of a young male with acute renal failure and acute respiratory distress syndrome in the setting of acute traumatic brain injury.
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Affiliation(s)
- Joshua E Medow
- Department of Neurosurgery, University of Wisconsin, Madison, WI USA
| | - Shalin R Sanghvi
- Department of Medicine, Section of Nephrology, University of Wisconsin, Madison, WI USA
| | - R Michael Hofmann
- Department of Medicine, Section of Nephrology, University of Wisconsin, Madison, WI USA
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Zarbock A, John S, Jörres A, Kindgen-Milles D. [New KDIGO guidelines on acute kidney injury. Practical recommendations]. Anaesthesist 2015; 63:578-88. [PMID: 24981152 DOI: 10.1007/s00101-014-2344-5] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The incidence of acute kidney injury (AKI) in critically ill patients is very high and is associated with an increased morbidity and mortality. In 2012 the Kidney Disease: Improving Global Outcome (KDIGO) guidelines were published in which evidence-based practical recommendations are given for the evaluation and management of patients with AKI. The first section of the KDIGO guidelines deals with the unification of earlier consensus definitions and staging criteria for AKI. The subsequent sections of the guidelines cover the prevention and treatment of AKI as well as the management of renal replacement therapy (RRT) in patients with AKI. In each section the existing evidence is discussed and a specific treatment recommendation is given. The guidelines appreciates that there is insufficient evidence for many of the recommendations. As a specific pharmacological therapy is missing, an early diagnosis, aggressive hemodynamic optimization, tight volume control, and avoidance of nephrotoxic drugs are the only interventions to prevent AKI. If renal replacement therapy is required different modalities are available to provide an effective therapy with a low rate of adverse effects.
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Affiliation(s)
- A Zarbock
- Klinik für Anästhesiologie, operative Intensivmedizin und Schmerztherapie, Universitätsklinikum Münster, Albert-Schweitzer Str. 33, 48149, Münster, Deutschland,
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Nongnuch A, Panorchan K, Davenport A. Brain-kidney crosstalk. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:225. [PMID: 25043644 PMCID: PMC4075125 DOI: 10.1186/cc13907] [Citation(s) in RCA: 100] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Encephalopathy and altered higher mental functions are common clinical complications of acute kidney injury. Although sepsis is a major triggering factor, acute kidney injury predisposes to confusion by causing generalised inflammation, leading to increased permeability of the blood–brain barrier, exacerbated by hyperosmolarity and metabolic acidosis due to the retention of products of nitrogen metabolism potentially resulting in increased brain water content. Downregulation of cell membrane transporters predisposes to alterations in neurotransmitter secretion and uptake, coupled with drug accumulation increasing the risk of encephalopathy. On the other hand, acute brain injury can induce a variety of changes in renal function ranging from altered function and electrolyte imbalances to inflammatory changes in brain death kidney donors.
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Bansal VK, Bansal S. Nervous system disorders in dialysis patients. HANDBOOK OF CLINICAL NEUROLOGY 2014; 119:395-404. [DOI: 10.1016/b978-0-7020-4086-3.00025-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
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Randomized trial of frequent low-efficiency and short hemodialysis/hemofiltration in hemodialysis patients with acute brain injury. Int J Artif Organs 2013; 36:793-802. [PMID: 24338654 DOI: 10.5301/ijao.5000249] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/04/2013] [Indexed: 11/20/2022]
Abstract
PURPOSE The aim of the study was to compare effects of frequent low-efficiency and short hemodialysis (FLESHD) and frequent low-efficiency and short hemofiltration (FLESHF) in hemodialysis (HD) patients with acute brain injury (ABI).
METHODS We randomly divided 13 HD patients with ABI into FLESHD (n = 6) or FLESHF (n = 7) groups. Conditions for the first to third sessions were as follows. FLESHD intravenous administration of glycerol 400 ml/session, blood flow rate (QB) 100 ml/min, dialysate flow rate 300 ml/min, and treatment duration 2 h (HD-1). FLESHF intravenous administration of glycerol 400 ml/session, QB 150 ml/min, substitution flow rate 10 l/session, and treatment duration 4 h (HF-1). After the fourth session, we gradually changed the conditions and stopped glycerol administration (HD-2 and HF-2).
RESULTS There were no significant differences in survival rate, consciousness level, or adverse effects during hospitalization in either group. In mixed model analysis, the level of HCO3- post FLESHF was significantly (p<0.0001) increased compared with the level post FLESHD. However, no significant differences were seen in the levels of osmolality, in blood pressure before and after either dialysis method, or in the level of HCO3- pre dialysis. The variation in the relative ratio of BUN before FLESHF was significantly higher (p<0.05) than the relative ratio before FLESHD in the sixth session. In the FLESHD groups, serum sodium was higher and serum potassium was lower than in the FLESHF groups.
CONCLUSIONS FLESHD with glycerol under these conditions may be a better therapeutic option for managing patients with ABI, although the short-term survival rate is similar.
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Palevsky PM, Liu KD, Brophy PD, Chawla LS, Parikh CR, Thakar CV, Tolwani AJ, Waikar SS, Weisbord SD. KDOQI US Commentary on the 2012 KDIGO Clinical Practice Guideline for Acute Kidney Injury. Am J Kidney Dis 2013; 61:649-72. [DOI: 10.1053/j.ajkd.2013.02.349] [Citation(s) in RCA: 439] [Impact Index Per Article: 39.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2013] [Accepted: 02/12/2013] [Indexed: 01/22/2023]
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Palevsky PM. Renal replacement therapy in acute kidney injury. Adv Chronic Kidney Dis 2013; 20:76-84. [PMID: 23265599 PMCID: PMC3531877 DOI: 10.1053/j.ackd.2012.09.004] [Citation(s) in RCA: 45] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2012] [Revised: 09/26/2012] [Accepted: 09/27/2012] [Indexed: 12/21/2022]
Abstract
Although the use of renal replacement therapy (RRT) to support critically ill patients with acute kidney injury (AKI) has become routine, many of the fundamental questions regarding optimal management of RRT remain. This review summarizes current evidence regarding the timing of initiation of RRT, the selection of the specific modality of RRT, and prescription of the intensity of therapy. Although absolute indications for initiating RRT-such as hyperkalemia and overt uremic symptoms-are well recognized, the optimal timing of therapy in patients without these indications continues to be a subject of debate. There does not appear to be a difference in either mortality or recovery of kidney function associated with the various modalities of RRT. Finally, providing higher doses of RRT is not associated with improved clinical outcomes.
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Affiliation(s)
- Paul M Palevsky
- VA Pittsburgh Healthcare System and University of Pittsburgh School of Medicine, Pittsburgh, PA 15240, USA.
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Friedrich JO, Wald R, Bagshaw SM, Burns KEA, Adhikari NKJ. Hemofiltration compared to hemodialysis for acute kidney injury: systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R146. [PMID: 22867021 PMCID: PMC3580734 DOI: 10.1186/cc11458] [Citation(s) in RCA: 95] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2012] [Accepted: 08/06/2012] [Indexed: 11/29/2022]
Abstract
Introduction The objective of this systematic review and meta-analysis was to determine the effect of renal replacement therapy (RRT), delivered as hemofiltration vs. hemodialysis, on clinical outcomes in patients with acute kidney injury (AKI). Methods MEDLINE, EMBASE and CENTRAL databases and conference abstracts were searched to June 2012 for parallel-group or crossover randomized and quasi-randomized controlled trials (RCTs) evaluating hemofiltration vs. hemodialysis in patients with AKI. Two authors independently selected studies and abstracted data on study quality and outcomes. Additional information was obtained from trial authors. We pooled data using random-effects models. Results Of 6,657 citations, 19 RCTs (10 parallel-group and 9 crossover) met inclusion criteria. Sixteen trials used continuous RRT. Study quality was variable. The primary analysis included three parallel-group trials comparing similar doses of hemofiltration and hemodialysis; sensitivity analyses included trials comparing combined hemofiltration-hemodialysis or dissimilar doses. We found no effect of hemofiltration on mortality (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.73 to 1.25, P = 0.76; three trials, n = 121 (primary analysis); RR 1.10, 95% CI 0.88 to 1.38, P = 0.38; eight trials, n = 540 (sensitivity analysis)) or other clinical outcomes (RRT dependence in survivors, vasopressor use, organ dysfunction) compared to hemodialysis. Hemofiltration appeared to shorten time to filter failure (mean difference (MD) -7 hours, 95% CI (-19,+5), P = 0.24; two trials, n = 50 (primary analysis); MD -5 hours, 95% CI (-10, -1), P = 0.01; three trials, n = 113 (including combined hemofiltration-hemodialysis trials comparing similar doses); MD -6 hours, 95% CI (-10, -1), P = 0.02; five trials, n = 383 (sensitivity analysis)). Data primarily from crossover RCTs suggested that hemofiltration increased clearance of medium to larger molecules, including inflammatory cytokines, compared to hemodialysis, although almost no studies measured changes in serum concentrations. Meta-analyses were based on very limited data. Conclusions Data from small RCTs do not suggest beneficial clinical outcomes from hemofiltration, but confidence intervals were wide. Hemofiltration may increase clearance of medium to larger molecules. Larger trials are required to evaluate effects on clinical outcomes.
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Lim SH, Lee YJ, Joe HB, Lee JM, Lee IK. Successful Brain Dead Donor Management with CRRT - A Case Report -. Korean J Crit Care Med 2012. [DOI: 10.4266/kjccm.2012.27.4.286] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Sang-Hyun Lim
- Department of Thoracic and Cardiovascular Surgery, Ajou University School of Medicine, Suwon, Korea
| | - Young-Joo Lee
- Department of Anesthesiology, Ajou University School of Medicine, Suwon, Korea
| | - Han Bum Joe
- Department of Anesthesiology, Ajou University School of Medicine, Suwon, Korea
| | - Jae-Moung Lee
- Department of Anesthesiology, Ajou University School of Medicine, Suwon, Korea
| | - In-Kyung Lee
- Department of Anesthesiology, Ajou University School of Medicine, Suwon, Korea
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Bagshaw SM, Bellomo R, Devarajan P, Johnson C, Karvellas CJ, Kutsiogiannis DJ, Mehta R, Pannu N, Romanovsky A, Sheinfeld G, Taylor S, Zappitelli M, Gibney RTN. Review article: Renal support in critical illness. Can J Anaesth 2010; 57:999-1013. [PMID: 20931311 DOI: 10.1007/s12630-010-9376-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2010] [Accepted: 08/12/2010] [Indexed: 01/20/2023] Open
Abstract
PURPOSE This review provides a focused and comprehensive update on established and emerging evidence in acute renal replacement therapy (RRT) for critically ill patients with acute kidney injury (AKI). PRINCIPAL FINDINGS There have been considerable technological innovations in the methods and techniques for provision of extracorporeal RRT in critical illness. These have greatly expanded our capability to provide both renal and non-renal life-sustaining organ support for critically ill patients. Recent data suggest earlier initiation of RRT in AKI may confer an advantage for survival and renal recovery. Two large trials have recently shown no added benefit to augmented RRT dose delivery in AKI. Observational data have also suggested that fluid accumulation in critically ill patients with AKI is associated with worse clinical outcome. However, several fundamental clinical questions remain to be answered, including issues regarding the time to ideally initiate/discontinue RRT, the role of high-volume hemofiltration or other blood purification techniques in sepsis, and extracorporeal support for combined liver-kidney failure. Extracorporeal support with RRT in sepsis, rhabdomyolysis, and liver failure are discussed, along with strategies for drug dosing and management of RRT in sodium disorders. CONCLUSIONS We anticipate that this field will continue to expand to promote research and innovation, hopefully for the benefit of sick critically ill patients.
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Affiliation(s)
- Sean M Bagshaw
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB T6G 2B7, Canada.
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Continuous Renal Replacement Therapy for Refractory Intracranial Hypertension? ACTA ACUST UNITED AC 2010; 68:1506-9. [DOI: 10.1097/ta.0b013e3181dbbf1b] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Abstract
Continuous renal replacement therapy (CRRT) is becoming the treatment of choice for critically ill patients with acute renal failure around the world. In particular, CRRT is used for patients with combined liver and acute renal failure, because they are often hemodynamically unstable. The question arises as to whether the use of CRRT should be extended to those patients with acute and chronic liver failure who do not have dialysis-dependent renal failure. CRRT could potentially allow some detoxification by removing water-soluble toxins and also allow regulation of intravascular volume and correction of sodium and other electrolyte and acid-base imbalances. By providing homeostatic control, CCRT could potentially help support patients by bridging to liver transplantation and managing those who eventually recover with hepatic regeneration.
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Affiliation(s)
- Andrew Davenport
- Royal Free and University College Hospital Medical School, Center for Nephrology, Royal Free Hospital, London, UK.
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Fletcher JJ, Bergman K, Feucht EC, Blostein P. Continuous renal replacement therapy for refractory intracranial hypertension. Neurocrit Care 2009; 11:101-5. [PMID: 19267223 DOI: 10.1007/s12028-009-9197-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
INTRODUCTION Little is known about the effects of hemodialysis on the injured brain, however; concern exists over the use of intermittent hemodialysis in patients with acute brain injury (ABI) due to its hemodynamic effects and increased intracranial pressure (ICP) associated with therapy. Continuous renal replacement therapy (CRRT) has become the preferred method of renal support in these patients though there is limited data to support its safety. Furthermore, exacerbations of cerebral edema have been reported. CRRT is an option for the treatment of hypervolemia and in theory may improve intracranial compliance. We report the case of a poly-trauma patient with severe traumatic brain injury (TBI) in which CRRT was implemented solely for refractory intracranial hypertension. METHODS A 28-year-old male was involved in a high-speed motor vehicle collision suffering a severe TBI and polytrauma. He required significant volume resuscitation. Intensive care unit course was complicated by shock, acute respiratory distress syndrome, ventilator associated pneumonia, and development of intracranial hypertension (IH). Data were collected by retrospective chart review. RESULTS Continuous hemofiltration was initiated for IH refractory to medical therapy. Within hours of initiation increase, ICP improved and normalized. Hemofiltration was safely discontinued after 48 h. Modified Rankin Score was 2 at 90 days. CONCLUSION Though unproven, CRRT may be beneficial in patients with IH due to gentle removal of fluid, solutes, and inflammatory cytokines. Given the limited data on safety of CRRT in patients with ABI, we encourage further reports.
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Affiliation(s)
- Jeffrey J Fletcher
- Department of Neurology (Neurocritical Care), Bronson Methodist Hospital, 601 John Street Suite M-124, Kalamazoo, MI 49007, USA.
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Joannidis M. Continuous renal replacement therapy in sepsis and multisystem organ failure. Semin Dial 2009; 22:160-4. [PMID: 19426421 DOI: 10.1111/j.1525-139x.2008.00552.x] [Citation(s) in RCA: 53] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
This study reviews the role of continuous renal replacement therapy (CRRT) in sepsis with acute kidney injury (AKI) and septic shock with multiple organ failure. In addition to the conventional aim of replacing renal function in AKI, CRRT is often used with the concept of modulating immune response in sepsis. With the intention of influencing circulating levels of inflammatory mediators like cytokines and chemokines, the complement system, as well as factors of the coagulation system, several modifications of CRRT have been developed over the last years. These include high volume hemofiltration, high adsorption hemofiltration, use of high cut-off membranes, and hybrid systems like coupled plasma filtration absorbance. One of the most promising concepts may be the development of renal assist devices using renal tubular cells for implementing renal tubular function into CRRT.
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Affiliation(s)
- Michael Joannidis
- Intensive Care Unit, Department of Internal Medicine I, Medical University of Innsbruck, Anichstrasse 35, Innsbruck, Austria.
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Abstract
PURPOSE OF REVIEW The mortality of acute liver failure remains unacceptably high and liver transplantation is the only effective treatment available to date. This review focuses on new research developments in the field and aims to provide a pragmatic organ-based treatment approach for liver failure patients requiring intensive care support. RECENT FINDINGS The pathophysiological basis for cerebral edema formation in acute liver failure continued to be the focus of various investigations. In-vivo observations confirmed the link between ammonia, cerebral glutamine content and intracranial hypertension. The role of arterial ammonia as an important prognostic indicator formed the basis of prospective, observational studies. Reduced monocytic HLA-DR expression linked acute liver failure with poor prognosis, and the cerebral effects and side effects of vasoactive therapy with terlipressin were investigated with two studies showing contradictory results. SUMMARY Despite increased knowledge of the pathophysiological events leading to organ dysfunction in acute liver failure, supportive treatment options remain limited in their efficacy and largely noncurative.
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Davies HT, Leslie GD. Intermittent versus continuous renal replacement therapy: a matter of controversy. Intensive Crit Care Nurs 2008; 24:269-85. [PMID: 18394900 DOI: 10.1016/j.iccn.2008.02.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2007] [Revised: 01/15/2008] [Accepted: 02/17/2008] [Indexed: 10/22/2022]
Abstract
BACKGROUND Acute Renal Failure (ARF) requiring some form of replacement therapy is a frequent complication in the critically ill patient. Despite potential therapeutic advantages the expectation of an improvement in patient outcomes using Continuous Renal Replacement Therapy (CRRT) compared to conventional Intermittent Haemodialysis (IHD) remains controversial. AIMS AND METHOD This article will review the literature on the issues surrounding the use of IHD versus CRRT in the management of the critically ill patient. Articles were selected according to level of evidence with priority given to meta-analyses and randomised controlled trials. DISCUSSION Several operational features of CRRT allow this technique to be tolerated more easily in critical illness than IHD. The gradual removal of fluid reduces the incidence of hypotension and the risk of volume overload. Decreased variability in the concentration of solutes enables greater azotemia control. However, CRRT is required to operate uninterrupted to achieve a treatment dose that is equivalent to a conventional IHD treatment schedule. In the absence of definitive evidence to validate superior patient survival and return of renal function there is disagreement as to the most appropriate form of Renal Replacement Therapy (RRT) for the critically ill patient. The introduction of 'hybrid' therapies offers a further alternative treatment strategy, which combine favourable aspects of IHD and CRRT. CONCLUSION The decision to use IHD or CRRT should be guided by the therapeutic needs of the patient rather than the operational differences between the two techniques. The resources and expertise available at the organisation are also important in determining the mode best able to manage the critically ill patient at any stage and may change according to the severity of illness. The emergence of hybrid therapies provides a compromise option which encompasses many of the features of both systems, but does not embrace all options of either approach.
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Affiliation(s)
- Hugh T Davies
- Intensive Care Unit, Royal Perth Hospital, Curtin University of Technology, Western Australia, Australia.
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Continuous versus intermittent renal replacement therapy for critically ill patients with acute kidney injury: A meta-analysis*. Crit Care Med 2008; 36:610-7. [DOI: 10.1097/01.ccm.0b013e3181611f552] [Citation(s) in RCA: 260] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Continuous Renal Replacement Therapy. Crit Care Med 2008. [DOI: 10.1016/b978-032304841-5.50021-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
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Rabindranath K, Adams J, Macleod AM, Muirhead N. Intermittent versus continuous renal replacement therapy for acute renal failure in adults. Cochrane Database Syst Rev 2007:CD003773. [PMID: 17636735 DOI: 10.1002/14651858.cd003773.pub3] [Citation(s) in RCA: 112] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Renal replacement therapy (RRT) for acute renal failure (ARF) can be applied intermittently (IRRT) or continuously (CRRT). It has been suggested that CRRT has several advantages over IRRT including better haemodynamic stability, lower mortality and higher renal recovery rates. OBJECTIVES To compare CRRT with IRRT to establish if any of these techniques is superior to each other in patients with ARF. SEARCH STRATEGY We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL). Authors of included studies were contacted, reference lists of identified studies and relevant narrative reviews were screened. Search date: October 2006. SELECTION CRITERIA RCTs comparing CRRT with IRRT in adult patients with ARF and reporting prespecified outcomes of interest were included. Studies assessing CAPD were excluded. DATA COLLECTION AND ANALYSIS Two authors assessed trial quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) for dichotomous outcomes or mean difference (WMD) for continuous data with 95% confidence intervals (CI). MAIN RESULTS We identified 15 studies (1550 patients). CRRT did not differ from IRRT with respect to in-hospital mortality (RR 1.01, 95% CI 0.92 to 1.12), ICU mortality (RR 1.06, 95% CI 0.90 to 1.26), number of surviving patients not requiring RRT (RR 0.99, 95% CI 0.92 to 1.07), haemodynamic instability (RR 0.48, 95% CI 0.10 to 2.28) or hypotension (RR 0.92, 95% CI 0.72 to 1.16) and need for escalation of pressor therapy (RR 0.53, 95% CI 0.26 to 1.08). Patients on CRRT were likely to have significantly higher mean arterial pressure (MAP) (WMD 5.35, 95% CI 1.41 to 9.29) and higher risk of clotting dialysis filters (RR, 95% CI 8.50 CI 1.14 to 63.33). AUTHORS' CONCLUSIONS In patients who are haemodynamically stable, the RRT modality does not appear to influence important patient outcomes, and therefore the preference for CRRT over IRRT in such patients does not appear justified in the light of available evidence. CRRT was shown to achieve better haemodynamic parameters such as MAP. Future research should focus on factors such as the dose of dialysis and evaluation of newer promising hybrid technologies such as SLED. Triallists should follow the recommendations regarding clinical endpoints assessment in RCTs in ARF made by the Working Group of the Acute Dialysis Quality Initiative Working Group.
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Cho KC, Himmelfarb J, Paganini E, Ikizler TA, Soroko SH, Mehta RL, Chertow GM. Survival by Dialysis Modality in Critically Ill Patients with Acute Kidney Injury. J Am Soc Nephrol 2006; 17:3132-8. [PMID: 17021268 DOI: 10.1681/asn.2006030268] [Citation(s) in RCA: 79] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
Among critically ill patients, acute kidney injury (AKI) requiring dialysis is associated with mortality rates generally in excess of 50%. Continuous renal replacement therapies (CRRT) often are recommended and widely used, although data to support its superiority over intermittent hemodialysis (IHD) are lacking. Data from the Program to Improve Care in Acute Renal Disease (PICARD), a multicenter observational study of AKI, were analyzed. Among 398 patients who required dialysis, the risk for death within 60 d was examined by assigned initial dialysis modality (CRRT [n = 206] versus IHD [n = 192]) using standard Kaplan-Meier product limit estimates, proportional hazards ("Cox") regression methods, and a propensity score approach to account for selection effects. Crude survival rates were lower for patients who were treated with CRRT than IHD (survival at 30 d 45 versus 58%; P = 0.006). Adjusted for age, hepatic failure, sepsis, thrombocytopenia, blood urea nitrogen, and serum creatinine and stratified by site, the relative risk for death associated with CRRT was 1.82 (95% confidence interval 1.26 to 2.62). Further adjustment for the propensity score did not materially alter the association (relative risk 1.92; 95% confidence interval 1.28 to 2.89). Among critically ill patients with AKI, CRRT was associated with increased mortality. Although the results could reflect residual confounding by severity of illness, these data provide no evidence for a survival benefit afforded by CRRT. Larger, prospective, randomized clinical trials to compare CRRT and IHD in severe AKI are needed.
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Affiliation(s)
- Kerry C Cho
- Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA 94118, USA
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Skinner H, Mackaness C, Bedforth N, Mahajan R. Cerebral haemodynamics in patients with chronic renal failure: effects of haemodialysis. Br J Anaesth 2004; 94:203-5. [PMID: 15531623 DOI: 10.1093/bja/aei016] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND We measured middle cerebral artery (MCA) flow velocity (FV), dynamic pressure autoregulation, and carbon dioxide reactivity (CRCO(2)) in patients with chronic renal failure before and after haemodialysis using transcranial Doppler ultrasonography. METHODS Twelve patients on long-term haemodialysis were recruited. MCA FV was measured continuously. The transient hyperaemic response test was used to assess cerebral autoregulation, and per cent change in FV per kPa change in end-tidal carbon dioxide was calculated to assess CRCO(2). All measurements were recorded before and after haemodialysis. RESULTS MCA FV (mean [sd]) decreased from 57 (10) cm s(-1) before to 46 (13) cm s(-1) after haemodialysis (P<0.01). The transient hyperaemic response ratio (THRR) was (mean [sd]) 1.29 (0.13) before haemodialysis and did not change significantly following haemodialysis (1.36 [0.10]). CRCO(2) was 21.7 (8.3)% kPa(-1) before haemodialysis and remained unchanged afterwards (20.9 [3.8]% kPa(-1)). Values in normal subjects for MCA FV, THRR and CRCO(2) are 56 (12) cm s(-1), 1.26 (0.13) and 22 (6)% kPa(-1), respectively. CONCLUSIONS MCA FV decreases significantly after haemodialysis. Dynamic pressure autoregulation and CRCO(2) remain normal in patients with chronic renal failure, and are not altered significantly by haemodialysis.
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Affiliation(s)
- H Skinner
- Department of Anaesthesia, Nottingham City Hospital and Queen's Medical Centre, Nottingham, UK.
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Liu JP, Gluud LL, Als-Nielsen B, Gluud C. Artificial and bioartificial support systems for liver failure. THE COCHRANE DATABASE OF SYSTEMATIC REVIEWS 2004. [PMID: 14974025 DOI: 10.1002/14651] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Artificial and bioartificial liver support systems may 'bridge' patients with acute or acute-on-chronic liver failure to liver transplantation or recovery. OBJECTIVES To evaluate beneficial and harmful effects of artificial and bioartificial support systems for acute and acute-on-chronic liver failure. SEARCH STRATEGY Trials were identified through The Cochrane Hepato-Biliary Group Controlled Trials Register (September 2002), The Cochrane Central Register of Controlled Trials on The Cochrane Library (Issue 3, 2002), MEDLINE (1966 - September 2002), EMBASE (1985 - September 2002), and The Chinese Biomedical Database (September 2002), manual searches of bibliographies and journals, authors of trials, and pharmaceutical companies. SELECTION CRITERIA Randomised clinical trials on artificial or bioartificial support systems for acute or acute on-chronic liver failure were included irrespective of blinding, publication status, or language. Non-randomised studies were included in explorative analyses. DATA COLLECTION AND ANALYSIS Data were extracted independently by three reviewers. Results were presented as relative risks (RR) with 95% confidence intervals (CI). Sources of heterogeneity were explored through sensitivity analyses and meta-regression. The primary outcome was mortality. MAIN RESULTS Twelve trials on artificial or bioartificial support systems versus standard medical therapy (483 patients) and two trials comparing different artificial support systems (105 patients) were included. Most trials had unclear methodological quality. Compared to standard medical therapy, support systems had no significant effect on mortality (RR 0.86; 95% CI 0.65-1.12) or bridging to liver transplantation (RR 0.87; 95% CI 0.73-1.05), but a significant beneficial effect on hepatic encephalopathy (RR 0.67; 95% CI 0.52-0.86). Meta-regression indicated that the effect of support systems depended on the type of liver failure (P = 0.03). In subgroup analyses, artificial support systems appeared to reduce mortality by 33% in acute-on-chronic liver failure (RR 0.67; 95% CI 0.51-0.90), but not in acute liver failure (RR 0.95; 95% CI 0.71-1.29). Two trials comparing artificial support systems showed significant mortality reductions with intermittent versus continuous haemofiltration (RR 0.58; 95% CI 0.36-0.94) and no significant difference between five versus ten hours of charcoal haemoperfusion (RR 1.03; 95% CI 0.65-1.62). The incidence of adverse events was inconsistently reported. REVIEWER'S CONCLUSIONS This Review indicates that artificial support systems may reduce mortality in acute-on-chronic liver failure. Artificial and bioartificial support systems did not appear to affect mortality in acute liver failure. However, considering the strength of the evidence additional randomised clinical trials are needed before any support system can be recommended for routine use.
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Affiliation(s)
- J P Liu
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, H:S Rigshospitalet, Blegdamsvej 9, Copenhagen, Denmark, DK 2100
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Liu JP, Gluud LL, Als‐Nielsen B, Gluud C. Artificial and bioartificial support systems for liver failure. Cochrane Database Syst Rev 2004; 2004:CD003628. [PMID: 14974025 PMCID: PMC6991941 DOI: 10.1002/14651858.cd003628.pub2] [Citation(s) in RCA: 53] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Artificial and bioartificial liver support systems may 'bridge' patients with acute or acute-on-chronic liver failure to liver transplantation or recovery. OBJECTIVES To evaluate beneficial and harmful effects of artificial and bioartificial support systems for acute and acute-on-chronic liver failure. SEARCH STRATEGY Trials were identified through The Cochrane Hepato-Biliary Group Controlled Trials Register (September 2002), The Cochrane Central Register of Controlled Trials on The Cochrane Library (Issue 3, 2002), MEDLINE (1966 - September 2002), EMBASE (1985 - September 2002), and The Chinese Biomedical Database (September 2002), manual searches of bibliographies and journals, authors of trials, and pharmaceutical companies. SELECTION CRITERIA Randomised clinical trials on artificial or bioartificial support systems for acute or acute on-chronic liver failure were included irrespective of blinding, publication status, or language. Non-randomised studies were included in explorative analyses. DATA COLLECTION AND ANALYSIS Data were extracted independently by three reviewers. Results were presented as relative risks (RR) with 95% confidence intervals (CI). Sources of heterogeneity were explored through sensitivity analyses and meta-regression. The primary outcome was mortality. MAIN RESULTS Twelve trials on artificial or bioartificial support systems versus standard medical therapy (483 patients) and two trials comparing different artificial support systems (105 patients) were included. Most trials had unclear methodological quality. Compared to standard medical therapy, support systems had no significant effect on mortality (RR 0.86; 95% CI 0.65-1.12) or bridging to liver transplantation (RR 0.87; 95% CI 0.73-1.05), but a significant beneficial effect on hepatic encephalopathy (RR 0.67; 95% CI 0.52-0.86). Meta-regression indicated that the effect of support systems depended on the type of liver failure (P = 0.03). In subgroup analyses, artificial support systems appeared to reduce mortality by 33% in acute-on-chronic liver failure (RR 0.67; 95% CI 0.51-0.90), but not in acute liver failure (RR 0.95; 95% CI 0.71-1.29). Two trials comparing artificial support systems showed significant mortality reductions with intermittent versus continuous haemofiltration (RR 0.58; 95% CI 0.36-0.94) and no significant difference between five versus ten hours of charcoal haemoperfusion (RR 1.03; 95% CI 0.65-1.62). The incidence of adverse events was inconsistently reported. REVIEWER'S CONCLUSIONS This Review indicates that artificial support systems may reduce mortality in acute-on-chronic liver failure. Artificial and bioartificial support systems did not appear to affect mortality in acute liver failure. However, considering the strength of the evidence additional randomised clinical trials are needed before any support system can be recommended for routine use.
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Affiliation(s)
- Jian Ping Liu
- Beijing University of Chinese MedicineCentre for Evidence‐Based Chinese Medicine 11 Bei San Huan Dong Lu, Chaoyang DistrictBeijingChina100029
| | - Lise Lotte Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 3344, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Bodil Als‐Nielsen
- Copenhagen Trial Unit, Centre for Clinical Intervention ResearchCochrane Hepato‐Biliary GroupRigshospitalet, Dept. 3344Blegdamsvej 9CopenhagenDenmarkDK‐2100
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, Department 3344, Rigshospitalet, Copenhagen University HospitalCochrane Hepato‐Biliary GroupBlegdamsvej 9CopenhagenDenmarkDK‐2100
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Sizer E, Wendon J, Bernal W. Acute Liver Failure in the ICU. Intensive Care Med 2003. [DOI: 10.1007/978-1-4757-5548-0_78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
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Abstract
In patients with severe liver failure, brain edema is a frequent and serious complication that may result in high intracranial pressure and brain damage. This short article focuses on basic physiologic principles that determine water flux across the blood-brain barrier. Using the Starling equation, it is evident that both the osmotic and hydrostatic pressure gradients are imbalanced across the blood-brain barrier in patients with acute liver failure. This combination will tend to favor cerebral capillary water influx to the brain. In contrast, the disequilibration of the Starling forces seems to be less pronounced in patients with cirrhosis because the regulation of cerebral blood flow is preserved and the arterial ammonia concentration is lower compared with that of patients with acute liver failure. Treatments that are known to reverse high intracranial pressure tend to decrease the osmotic pressure gradients across the blood-brain barrier. Recent studies indicate that interventions that restrict cerebral blood flow, such as hyperventilation, hypothermia, and indomethacin, are also efficient in preventing edema and high intracranial pressure, probably by decreasing the transcapillary hydrostatic pressure gradient. In our opinion, it is important to recall that rational fluid therapy, adequate ventilation, and temperature control are of direct importance to controlling cerebral capillary water flux in patients with acute liver failure. These simple interventions should be secured before more advanced experimental technologies are instituted to treat these patients.
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Liu J, Kjaergard LL, Als-Nielsen B, Gluud C. Artificial and bioartificial support systems for liver failure: a Cochrane Hepato-Biliary Group Protocol. LIVER 2002; 22:433-8. [PMID: 12390479 DOI: 10.1034/j.1600-0676.2002.01554.x] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
AIMS/BACKGROUND Liver support systems may bridge patients to liver transplantation or recovery from liver failure. This review is to evaluate the beneficial and harmful effects of artificial and bioartificial support systems for acute and acute-on-chronic liver failure. DATA SOURCES Randomized trials on any support system versus standard medical therapy will be included irrespective of publication status or language. Non-randomized studies are included in explorative analyses. Trials will be identified through bibliographies, correspondence with original investigators, and electronic searches (Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Controlled Trials Register, MEDLINE, EMBASE, and The Chinese Biomedical Database). METHODS OF THE REVIEW The extracted data will include characteristics of trials, patients, interventions, and all outcome measures. Methodological quality will be assessed by the randomization, follow up, and blinding. The RevMan and STATA will be used for statistical analyses. Sources of heterogeneity and methodological quality in the assessment of the primary outcome will be explored by sensitivity analyses and meta-regression.
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Affiliation(s)
- Jianping Liu
- The Cochrane Hepato-Biliary Group, The Copenhagen Trial Unit, Centre for Clinical Intervention Research, Copenhagen University Hospital, H:S Rigshospitalet, Blegdamsvej 9, DK-2100, Copenhagen, Denmark.
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Abstract
The search for a support system for liver failure has been intensified. Methods currently being tested include those based on artificial support, on biological approaches (including extracorporeal liver perfusion and transplanted hepatocytes) as well as hybrid devices that combine artificial aspects with biological systems. Each of these three areas is undergoing fast technological and conceptual development. Controlled clinical trials are also under way.
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Affiliation(s)
- L Kaptanoglu
- Departments of Medicine and Surgery, Northwestern University Medical School, Chicago, Illinois, USA
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Kanagasundaram NS, Paganini EP. Critical care dialysis--a Gordian knot (but is untying the right approach?). Nephrol Dial Transplant 1999; 14:2590-4. [PMID: 10534494 DOI: 10.1093/ndt/14.11.2590] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Abstract
The treatment of acute hepatic failure has developed rapidly over the last 40 years, reducing morbidity and mortality from this syndrome. Whilst this has been partly attributed to significant improvements in the specialist medical management of these patients, advances in surgical techniques and pharmaceutical developments have led to the establishment of successful liver transplantation programmes, which have improved mortality significantly. This review will examine the clinical impact of alternative methods that have been used to provide extra-corporeal hepatic support. Non-biological, bio- logical and hybrid hepatic extra-corporeal support will be explored, offering a comprehensive historical overview and an appraisal of present and future advances.
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Affiliation(s)
- T M Rahman
- Department of Gastroenterology, Imperial College School of Medicine, Hammersmith Hospital, London, UK
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Caruso DM, Vishteh AG, Greene KA, Matthews MR, Carrion CA. Continuous hemodialysis for the management of acute renal failure in the presence of cerebellar hemorrhage. Case report. J Neurosurg 1998; 89:649-52. [PMID: 9761062 DOI: 10.3171/jns.1998.89.4.0649] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
In this report the authors describe the use of continuous venovenous hemodialysis (CVVHD) in a medically unstable patient who suffered from a spontaneous cerebellar hemorrhage. Conventional dialysis techniques carry the risk of developing the dialysis disequilibrium syndrome (DDS) when performed in the presence of a variety of intracranial diseases. The CVVHD technique was used successfully in a morbidly obese, short-statured woman with a spontaneous hypertensive intraparenchymal cerebellar hemorrhage. The woman experienced acute renal failure several days after her hemorrhage and her general medical condition prevented her from undergoing surgical evacuation. The CVVHD did not result in elevations in intracranial pressure (ICP) and the patient made a full recovery from both acute renal failure and life-threatening posterior fossa hemorrhage. This case is noteworthy because of the absence of abnormally high ICP elevations or development of DDS in a patient with a large acute posterior fossa intraparenchymal brain hemorrhage and acute renal failure whose case was managed with CVVHD in the acute period.
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Affiliation(s)
- D M Caruso
- Department of Surgery, Maricopa Medical Center, Phoenix, Arizona, USA
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Maxvold NJ, Smoyer WE, Gardner JJ, Bunchman TE. Management of acute renal failure in the pediatric patient: hemofiltration versus hemodialysis. Am J Kidney Dis 1997; 30:S84-8. [PMID: 9372984 DOI: 10.1016/s0272-6386(97)90547-3] [Citation(s) in RCA: 50] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Although outcome data for acute renal failure (ARF) in the adult population (analyzed by etiology of ARF, severity of illness, and modality of treatment) are readily available, few similar data exist for the pediatric population. Pediatric survival rate data vary widely, based upon era of analysis, age and size of child, and cause of ARF. Few comparative data are available that address impact by modality chosen to treat ARF. Comparison of 122 children who were treated by hemodialysis (HD; n = 58) versus hemofiltration (HF; n = 64) reveals a combined survival rate of 65%. Survival by modality was higher for HD (83%) than for HF (48%). The major diagnosis treated with HF was sepsis (29/64; 45%), with a survival rate of 31%, whereas the major diagnosis treated with HD (27/58; 46%) was primary renal failure, with a survival rate of 96%. Seventy-one percent of children undergoing HF required pressor support for hypotension, whereas only 24% of those receiving HD needed pressor support (P < 0.01). We conclude that the choice of renal replacement therapy (RRT) modality needs to be determined by the best treatment available. To adequately evaluate therapy measures, further analyses of outcome need to consider those factors that determine choice of RRT and those that affect survival independent of ARF.
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Affiliation(s)
- N J Maxvold
- University of Michigan Medical Center, Mott Children's Hospital, Ann Arbor 48109, USA
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Affiliation(s)
- J G O'Grady
- Institute of Liver Studies, King's College Hospital, London, UK.
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Ichai C, Fenouil E, Grimaud D. [Osmolality and brain]. ANNALES FRANCAISES D'ANESTHESIE ET DE REANIMATION 1994; 13:68-79. [PMID: 8092583 DOI: 10.1016/s0750-7658(94)80189-4] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
A modification of serum osmolarity induces always movements of water across cell membranes and therefore variations of cell volume of all tissues, including brain. To avoid a severe cell dehydration or hyperhydration, the organism has several regulation means called osmoregulation. Cerebral osmoregulation is essential as the brain is contained in a unexpandable box. In comparison with other organs, this phenomenon is complex and particular as: 1) cerebral volume consists of 3 sub spaces (intracellular, extracellular and cerebrospinal fluid [CSF]); 2) exists a blood-brain barrier (BBB) which behaves functionally as a semi-permeable membrane, essentially sensitive to osmolar disturbances. This brain volume regulation mechanism is working whatever the nature of the solutes initiating the osmotic deviation (sodium, glucose, mannitol...). Cerebral osmoregulation results from intracerebral osmolar modifications. Thus, every variation of plasma osmolarity elicits a similar variation of intracerebral osmolarity. This phenomenon results from modifications of the brain cell "protective" osmoles content. When the osmolar disturbance occurs quickly (in a few hours), cerebral osmoregulation is not complete. It results essentially from modifications of brain cell inorganic solutes content, i.e. electrolytes (Na, K, Cl) which originate from plasma, CSF and extracellular brain spaces uptake. When the osmolar disturbance is more progressive, cerebral osmoregulation is complete. The brain volume returns then to its initial value, by increasing its brain cell electrolytes, but above all organic "idiogenic" osmoles content. These idiogenic osmoles are identified as amino acids, polyols and trimethylamines. During treatment, the delayed normalization of brain osmolarity compared with plasma osmolarity prescribes a slow correction of the osmolar disturbance, as much as it is a chronic one.
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Affiliation(s)
- C Ichai
- Département d'Anesthésie-Réanimation, Hôpital Saint-Roch, Nice
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