**8. References**

244 Progress in Hemodialysis – From Emergent Biotechnology to Clinical Practice

intermittent volume and solute fluxes may cause significant morbidity, which includes worsening of hypotension and arrhythmias. Multiple modalities of renal replacement therapy are currently available. These include intermittent hemodialysis (IHD), continuous renal replacement therapies (CRRTs), and hybrid therapies, such as sustained low-efficiency

**INDICATIONS FOR AND TIMING OF INITIATION OF DIALYSIS — Accepted indications for renal replacement therapy (RRT) in patients with Acute Kidney Injury** 

**Hyperkalemia (plasma potassium concentration >6.5 meq/L) refractory to medical** 

**Signs of uremia, such as pericarditis, neuropathy, or an otherwise unexplained decline** 

CRRTs involve either dialysis (diffusion-based solute removal) or filtration (convectionbased solute and water removal) treatments that operate in a continuous mode (114-117). The major advantage of continuous therapy is the slower rate of solute or fluid removal per unit of time. Thus, CRRT is generally better tolerated than conventional therapy, since many of the complications of intermittent hemodialysis are related to the rapid rate of solute and fluid loss. It must be emphasized, however, that the protection afforded by CRRT is relative,

Outcomes of an increased dose of CRRT have been assessed in several randomized controlled trials and two meta-analyses (78-80,116-117). Conflicting results related to survival have been reported. To address the issue of optimal dose in CRRT and IHD, the United States VA/NIH Acute Renal Failure Trial Network study (ATN), the Randomized Evaluation of Normal versus Augmented Level of RRT study (RENAL) and two metaanalyses were performed. All studies found that, compared with standard intensity dialysis,

In the United States VA/NIH Acute Renal Failure Trial Network study (ATN), all 1124 patients were treated with IHD, CRRT, or SLED based upon hemodynamic status. Patients



The death rate at day 60 was the same for both groups (53.6 percent with intensive therapy and 51.5 percent with less intensive therapy). In addition, the duration of renal replacement therapy and the rate of recovery of kidney function or nonrenal organ failure were similar for both treatment arms. The group that received intensive therapy had an increased number of hypotensive episodes. Thus, more intensive renal support beyond that obtained

higher intensity dialysis did not result in improved survival or clinical benefits:

CRRT was provided with a flow rate of 20 mL/kg per hour.

were randomly assigned to one of two dosing arms:

**Metabolic acidosis (pH less than 7.1) refractory to medical therapy.** 

dialysis (SLED).

**therapy** 

not absolute.

**7. Outcomes in CRRT** 

35 mL/kg per hour.

**in mental status** 

**(AKI) generally include: Refractory fluid overload** 

**Certain alcohol and drug intoxications** 


Hemodialysis Principles and Controversies 247

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**Part 2** 

**Prognosis** 


**Part 2** 

**Prognosis** 

252 Progress in Hemodialysis – From Emergent Biotechnology to Clinical Practice

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**13** 

**Residual Renal Function in** 

James F. Winchester1 and Michael Bergman3

Zachary Z. Brener1, Stephan Thijssen2, Peter Kotanko2,

The role of residual renal function (RRF) in the health and quality of life of both pre-dialysis and dialysis patients is equally important and now well established (Termorshuizen,

RRF plays an important role in maintaining fluid balance, phosphorus control, and removal of uremic toxins in dialysis patients. The importance of RRF in hemodialysis (HD) patients is less well appreciated and it is believed that RRF declined rapidly in HD patients (Morduchowicz, Winkler et al, 1994; Wang, Woo, et al, 2005). Decline of RRF also contributed significantly to anemia, inflammation, and malnutrition in end-stage renal disease (ESRD) patients (Wang, Sea et al, 2001; Pecoits-Filho, Heimburger et al, 2003; Pecoits-Filho, Heimburger et al, 2002; Wang, Wang et al, 2004). More importantly, RRF has also been shown to be a powerful predictor of mortality, especially in patients on peritoneal dialysis (PD) (Bargman, Thorpe et al, 2001; Brener, Thijssen et al, 2011; Maiorca, Brunori et

Glomerular filtration rate (GFR) measured by isotope clearance is considered to be the standard measure of renal function. Other tests, such as serum creatinine, creatinine clearance, urea clearance, an average of the creatinine and urea clearances, and urine volume have been used to assess RRF in chronic kidney disease (Levey, 1990). Despite its limitations, urine volume, the simplest measure of RRF, has been correlated to GFR in studies and most authors defined loss of RRF as urine volume < 200 ml/24 hours (Moist, Port et al, 2000). Urine collections (24 hours for PD, interdialytic for HD) to measure urea and/or creatinine clearance usually done at beginning of chronic dialysis and every 1-3

In this chapter, we will review available data that have shown a positive impact of RRF on the survival and quality of life of dialysis patients, and outline the current strategies to

**1. Introduction** 

Korevaar et al, 2003).

al, 19951).

months in patients with RRF.

preserve RRF in PD and HD patients.

**Hemodialysis Patients** 

*1Beth Israel Medical Center, New York; 2Renal Research Institute, New York 3Rabin Medical Center – Campus Golda,* 

*Tel-Aviv University* 

*1,2USA 3Israel* 
