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Continuous Renal Replacement Therapy Machine Technology

Objectives This chapter will: 1. Provide a brief history of the development and evolution of continuous renal replacement therapy (CRRT) systems. 2. Describe the basic features of CRRT machines, including the user interface, pumps, pressure monitoring, safety features, and anticoagulation capabilities. 3. Understand the basic principles of CRRT membranes and filters, especially with regard to the influence of modality, membrane characteristics, and blood/fluid flows on solute…

Membranes and Filters for Use in Acute Renal Failure

Objectives This chapter will: 1. Describe the main components of filter and membranes for continuous renal replacement therapy (CRRT). 2. Characterize the performance parameters of filters and membranes. 3. Describe the fundamentals of solute and fluid transport in CRRT. Renal support for acute kidney injury (AKI) relies on various dialysis methods whose origin may be traced to methods used primarily in the treatment of end-stage renal…

Principles of Extracorporeal Circulation and Transport Phenomena

Objectives This chapter will: 1. Present a brief overview of the main components of the extracorporeal circulation for renal replacement therapies. 2. Explain the safety features involved in the delivery of these therapies. 3. Describe the implications of the principal mechanisms of water and solute transport as the basis of renal replacement therapies. During renal replacement therapy (RRT), blood circulates through an extracorporeal circuit, in which…

Indications for Renal Replacement Therapy in the Critically Ill

Objectives This chapter will: 1. Describe renal indications of renal replacement therapy. 2. Identify nonrenal indications of renal replacement therapy. 3. Discuss the timing of renal replacement therapy in the intensive care unit. The primary goal of renal replacement therapy (RRT) is to compensate for the abrupt loss of renal function, which characterizes severe acute kidney injury (AKI). Disturbances associated with AKI are volume overload, accumulation…

Mechanical Fluid Removal

Objectives This chapter will: 1. Provide an overview of the different types of mechanical fluid removal and their risks and benefits. 2. Summarize the results of clinical trials in this field. Fluid overload is common during critical illness. There are a number of potential reasons why patients may be fluid overloaded. They may be fluid overloaded on admission to hospital, as in decompensated heart failure, or…

Management of Fluid Overload in Cardiorenal Patients: The Five B Approach

Objectives This chapter will: 1. Describe the conditions leading to fluid derangement in cardiorenal syndromes. 2. Propose a structured approach for the diagnosis and management of the cardiorenal patient with fluid overload. 3. Define five steps in the management of fluid balance during conservative management and during extracorporeal fluid removal: a) Balance of fluids (reflected by body weight); b) Blood pressure monitoring; c) Biomarker profile; d)…

Noninvasive Methods of Fluid Status Assessment in Critically Ill Patients

Objectives This chapter will: 1. Discuss the importance of fluid status assessment in the setting of the intensive care unit and the correlation between fluid overload and adverse outcomes in critically ill patients. 2. Describe noninvasive methods to assess fluid status (i.e., physical examination, fluid balance recording, chest radiography, ultrasonography techniques) and their role in the management of intensive care patients. 3. Focus on bioimpedance methods…

Components of Fluid Balance and Monitoring

Objectives This chapter will: 1. Review the pathophysiology related to fluid status and the four phases of fluid resuscitation. 2. Review clinical parameters available to assess fluid volume, fluid responsiveness, and fluid overload. 3. Discuss practical issues regarding fluid administration and removal in hospitalized and critically ill patients. Fluid administration is one of the most frequently used therapies provided in hospitalized patients. The most common reasons…

Effect of Extracorporeal Therapies on the Brain

Objectives This chapter will: 1. Describe the effect of hemodialysis and peritoneal dialysis on stroke and cognitive function. 2. Discuss dialysis adequacy, acute disturbances such as delirium, and dialysis disequilibrium syndrome in using of hemodialysis and peritoneal dialysis. 3. Review considerations in the use of continuous renal replacement therapy over intermittent hemodialysis in a patient with an acute brain injury. 4. Explore the practical aspects and…

Renal Protection in the Organ Donor

Objectives This chapter will: 1. Provide an overview of deceased kidney donation and discuss donor medical suitability. 2. Describe the physiologic sequelae of brain death, the effect on organ function, and protective strategies that may prevent damage to transplantable organs. 3. Provide an overview of the clinical management of the brain-dead potential organ donor that will facilitate successful organ procurement, minimize organ damage, and optimize outcome…

Treatment of Combined Acute Renal Failure and Cerebral Edema

Objectives This chapter will: 1. Present the basic pathophysiology of cerebral edema. 2. Give the characteristics of patients at risk for cerebral edema. 3. Describe the standard supportive management of cerebral edema. 4. Discuss the issues to consider when prescribing renal support for the patient with cerebral edema. Basic Pathophysiology of Cerebral Edema In the normal, healthy adult, the skull acts as a rigid box, containing…

Extracorporeal Liver Support Devices

Objectives This chapter will: 1. Discuss the theoretical basis for the use of extracorporeal liver support devices (ECLSDs) in acute and chronic liver failure. 2. Describe the structure and function of current artificial and bioartificial ECLSDs. 3. Review the current the literature regarding the effectiveness of ECLSDs in the management of acute and chronic liver failure. The last 50 years have seen the increasingly successful use…

Kidney Dysfunction After Liver Transplantation

Objectives This chapter will: 1. Present the risk factors for early postoperative acute kidney injury after orthotopic liver transplantation (OLT), including pre-OLT, intraoperative factors, and post-OLT factors. 2. Present the factors affecting renal dysfunction in long-term survivors. 3. Suggest strategies to reduce risk factors. Acute kidney injury (AKI) is common immediately after orthotopic liver transplantation (OLT), whereas chronic kidney disease (CKD) and end-stage renal disease (ESRD)…

Pathophysiology and Management of the Hepatorenal Syndrome

Objectives This chapter will: 1. Discuss the characteristics and the clinical impact of hepatorenal syndrome. 2. Discuss the pathophysiology of hepatorenal syndrome. 3. Discuss the management and the available treatments of hepatorenal syndrome. Patients with advanced cirrhosis frequently show a certain degree of renal dysfunction, and a strong relationship between severity cirrhosis and renal dysfunction has been shown. It has been estimated that more than 20%…

Liver-Kidney Interaction

Objectives This chapter will: 1. Give the reader an overview of the liver as an acid-base organ. 2. Describe the complexities of the liver-kidney interaction at the molecular level. 3. Relate the pathophysiologic abnormalities of liver-kidney interactions to outcomes of kidney injury in patients with liver disease. The kidney is the primary organ for body-wide homeostasis, and disruption to its multiple functions has significant impact upon…

Pulmonary-Renal Syndrome

Objectives This chapter will: 1. Define the range of conditions causing immune-mediated alveolar and glomerular injury resulting in acute pulmonary complications, especially hemorrhage and acute kidney injury. 2. Explore the immunopathogenesis and clinical features of pulmonary-renal syndrome. 3. Describe relevant diagnostic techniques. 4. Discuss treatment in the context of recent evidence. Acute kidney injury and respiratory failure are common problems affecting patients in the intensive care…

Extracorporeal Membrane Oxygenation and Continuous Renal Replacement Therapy in Adults and Children

Objectives This chapter will: 1. Approach the concept of multi-organ support therapy focusing on the combined pulmonary-renal dysfunction in terms of incidence, extracorporeal support, and outcomes. 2. Describe technologies available to combine extracorporeal membrane oxygenation (ECMO) systems with continuous renal replacement therapies (RRT) machines. 3. Explain the advantages and the limitations of respiratory and renal extracorporeal support interaction. 4. Appraise the impact of RRT on outcomes…

Extracorporeal Carbon Dioxide Removal

Objectives This chapter will: 1. Explain the physiology of CO 2 removal during extracorporeal support. 2. Describe potential clinical applications of extracorporeal CO 2 removal systems (ECCO 2 R) support therapy in patients with acute respiratory distress syndrome (ARDS) and chronic obstructive pulmonary disease (COPD) as well as in those with acute kidney injury requiring renal replacement therapy. Mechanical ventilation (MV) is a lifesaving treatment delivered…

Extracorporeal Membrane Oxygenation and Renal Function

Objectives This chapter will: 1. Briefly summarize the definitions and markers of acute kidney injury. 2. Review the recent literature on incidence and outcomes of renal failure in patients supported with extracorporeal membrane oxygenation (ECMO), as well as the literature on the use of renal replacement therapy in ECMO patients. 3. Describe the relationship between ECMO and acute kidney injury, possible risk factors, and related pathophysiology.…

The Kidney During Mechanical Ventilation

Objectives This chapter will: 1. Describe the epidemiologic relationship between mechanical ventilation and acute renal failure and address the indications for mechanical ventilation. 2. Review the adverse effects of mechanical ventilation on the lung and distant organs. 3. Outline the effects of mechanical ventilation on systemic hemodynamics, local renal blood flow, and on the kidney. 4. Discuss the possible effects of hypercapnia and hypoxemia on kidney…