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Cascade Filtration for ABO Incompatible Transplant

Objectives This chapter will: 1. Briefly describe desensitization protocols used in ABO incompatible renal transplantation. 2. Describe the extracorporeal technique used to remove circulating antibodies against A and B antigens. 3. Describe the characteristics of cascade filtration. Barrier of ABO More than 30% of end-stage renal disease patients with an available living donor organ cannot be transplanted because of HLA or ABO incompatibility (ABOi). Such barriers…

The Role of Plasmapheresis in Critical Illness

Objectives This chapter will: 1. Review the techniques of plasmapheresis. 2. Review the indications and evidence for plasmapheresis and therapeutic plasma exchange in critical illness. Extracorporeal blood purification by plasmapheresis has been more streamlined and gained more interest by intensivists during the past decade. A useful document is the regularly updated “Guidelines on the Use of Therapeutic Apheresis in Clinical Practice—Evidence-Based Approach” published by the American…

Hybrid Dialysis Techniques in the Intensive Care Unit

Objectives This chapter will: 1. Define and give the rationale for hybrid renal replacement therapy. 2. Discuss the technical requirements of hybrid renal replacement therapy. 3. Explain the versatility and flexibility of hybrid renal replacement therapy prescription and provision. 4. Describe the effects of hybrid renal replacement therapy on control of small and larger solutes and on cardiovascular stability. 5. Review comparative outcome data. Hybrid therapy…

Outcomes of Intermittent Hemodialysis in Critically Ill Patients With Acute Kidney Injury

Objectives This chapter will: 1. Compare general short- and long-term outcomes of intermittent versus continuous dialysis modalities in patients with acute kidney injury. 2. Compare impact of intermittent dialysis versus continuous renal replacement therapies on hemodynamic stability and de novo chronic kidney disease (CKD) and progression to end-stage renal diseases. 3. Discuss contraindications to intermittent dialysis and on particular clinical problems, including vascular access, anticoagulation, and…

Assessment of Fluid Status and Body Composition and Control of Fluid Balance With Intermittent Hemodialysis in the Critically Ill Patient

Objectives This chapter will: 1. Discuss body composition in health and disease. 2. Describe the current tools used in evaluation of body composition and fluid status. 3. Consider intermittent hemodialysis in the critically ill patient for control of fluid balance and prevention of intradialytic hypotension. You’re Reading a Preview Become a Clinical Tree membership for Full access and enjoy Unlimited articles Become membership If you are…

Urea Kinetics, Efficiency, and Adequacy of Hemodialysis and Other Intermittent Treatments

Objectives This chapter will: 1. Examine methods for measuring intermittent renal replacement therapy in critically ill patients. 2. Review data documenting the response to different modes of intermittent renal replacement therapy. 3. Examine the effect of variables that affect the efficiency of solute removal. 4. Recommend methods to assess and improve the adequacy of renal replacement therapy in the intensive care unit. Hemodialysis first was used…

Correction of Water, Electrolyte, and Acid-Base Derangements by Hemodialysis and Derived Techniques

Objectives This chapter will: 1. Discuss the clinical implications of using different dialysate sodium concentrations when performing intermittent hemodialysis. 2. Describe how to safely manage patients with different degrees of hyponatremia and hypernatremia using intermittent hemodialysis. 3. Review the factors that influence potassium removal during intermittent hemodialysis. 4. Explain the effects of different dialysate calcium con­centrations on patients' electrolyte abnormalities and hemodynamics. 5. Show how to…

Technical and Clinical Complications of Intermittent Hemodialysis in the Intensive Care Unit

Objectives This chapter will: 1. Discuss the technical and clinical complications of hemodialysis in the intensive care unit. 2. Explain how to recognize and treat clinical and technical complications of this treatment. Acute kidney injury (AKI) requiring renal replacement therapy (RRT) in the intensive care unit (ICU) is a serious condition with a reported mortality rate as high as 50% to 80%. The choice of RRT…

Indications for and Contraindications to Intermittent Hemodialysis in Critically Ill Patients

Objectives This chapter will: 1. Describe the major technical differences between intermittent hemodialysis and continuous renal replacement therapies to treat acute renal failure in acutely ill patients. 2. Discuss the advantages and limitations of intermittent hemodialysis in this setting. 3. Describe some technical aspects of both methods to help physicians in the choice of the best method for each clinical situation. Until the early 1980s, intermittent…

Composition of Hemodialysis Fluid

Objectives This chapter will: 1. Describe the main electrolyte components of modern dialysate. 2. Characterize clinical effects of changes in concentration of major dialysate constituents. 3. Outline the requirements for purity of dialysis water. In a general sense, hemodialysis fluid can be considered a temporary “extension” of the patient's extracellular fluid. As a result of a blood-dialysate contact via pores in extracorporeal semipermeable membranes, diffusion takes…

Biocompatibility of the Dialysis System

Objectives This chapter will: 1. Present the fundamentals of biocompatibility of membranes and other factors contributing to the biocompatibility of dialysis. 2. Discuss the findings of meta-analyses concerned with the effect of biocompatibility on treatment outcomes. Biocompatibility may be defined as “the ability of a biomaterial to perform its desired function with respect to a medical therapy, without eliciting any undesirable local or systemic effects in…

Solute and Water Transport in Hemodialysis : Dialyzers, Flow Distribution, and Cross-Filtration

Objectives This chapter will: 1. Discuss the determinants of the two main dialysis mass transfer mechanisms, diffusion and convection, along with the factors influencing ultrafiltration. 2. Explain the concept of solute clearance and the various ways in which it is expressed. 3. Describe the basic characteristics of hollow fiber dialyzers and highlight the major features influencing ultrafiltra­tion properties and small and larger solute removal capabilities. Conventional…

Intermittent Techniques for Acute Dialysis

Objectives This chapter will: 1. Present the specificity to implement intermittent techniques to treat acute renal failure in the intensive care unit. 2. Review the evidence regarding the effect of the type of dialysis membrane and the dialysis dose on the outcome for the patient with acute renal failure. 3. Discuss the basic principles of prescribing intermittent hemodialysis for patients with acute renal failure, including treatments…

Ethical Considerations in Acute Renal Replacement Therapy

Objectives This chapter will: 1. Present the main bioethical problems associated with the management of renal replacement therapy (RRT) in critically ill patients. 2. Discuss a strategy, based on moral principles, for guiding the decision-making process. 3. Present a protocol to guide a practical possible approach to difficult decisions in critically ill patients. 4. Present and discuss some of the problems associated with clinical research in…

Principles of Pharmacodynamics and Pharmacokinetics of Drugs Used in Extracorporeal Therapies

Objectives This chapter will: 1. Identify the major factors affecting drug removal during renal replacement therapy (RRT). 2. Define the principles for appropriate dosage adjustments during RRT. 3. Describe the potential relevance of RRT in modifying the pharmacodynamic behavior of antimicrobial agents during RRT. When a drug is administered for therapeutic purposes, its pharmacodynamic effect is the result of the achievement and maintenance of therapeutically effective…

Quantification of Acute Renal Replacement Therapy

Objectives This chapter will: 1. Provide a clinical context for acute renal replacement therapy (RRT) dosing. 2. Discuss the role and limitations of urea kinetic modeling for the quantification of dose. 3. Discuss the concepts and demonstrate the use of practical tools for the quantification of dose that are specific to either intermittent or continuous RRT. 4. Discuss the concept and demonstrate the use of equivalent…

The Concept of Renal Replacement Therapy Dose and Efficiency

Objectives This chapter will: 1. Describe the main dimensions of renal replacement therapy (RRT) dose: efficiency, intensity, and clinical efficacy. 2. Describe the most important studies addressing the impact of RRT dose on the survival of critically ill patients. 3. Describe some practical concepts guiding the clinician to RRT prescription. The conventional view of renal replacement therapy (RRT) dose is that it is a measure of…

Starting and Stopping Renal Replacement Therapy in the Critically Ill

Objectives This chapter will: 1. Evaluate the factors that determine need for dialytic intervention in critically ill patients and describe the current status of initiation of renal replacement therapy in the intensive care unit (ICU). 2. Define and contrast approaches for renal replacement and renal support in the ICU. 3. Discuss the practical aspects of initiating and withdrawing dialysis in critically ill patients. Predictors for Dialysis…

Dialysis Solutions and Replacement Fluids

Objectives This chapter will: 1. Define the role of dialysis solutions and replacement fluids in the prescription of continuous renal replacement therapy (CRRT). 2. Provide updated information on the composition of commercially available CRRT solutions, focusing on the possibility to tailor CRRT prescription to individual patient needs. 3. Discuss the potential electrolyte and acid-base derangements related to the use of CRRT solutions. 4. Discuss the selection…

Principles of Anticoagulation in Extracorporeal Circuits

Anticoagulation Intermittent Hemodialysis Heparin Clotting Membrane There is a fine balance between hemostasis and hemorrhage in the human body, managed by a complex system of plasma, cellular, and endothelial factors. Coagulation is the normal process occurring when vascular injury results in the formation of a fibrin clot; thrombosis refers to the pathologic formation of clot in response to injury, stasis, and hypercoagulability. Intermittent and continuous dialysis…