Acute Renal Failure as Part of Multi-Organ Failure: How Long We Should Wait before We Intervene? A Dissection of Studies.

Mortality rate in multisystem organ failure (MOF) is very high. Acute renal failure is an important part of MOF. In this special feature article I have aimed to streamline the achievements of different studies on continuous renal replacement therapy (CRRT) for a fruitful outcome. For this I have gone for retrospective evaluation of the studies reached through PubMed, internet alert system of different journals, proceedings of conferences on CRRT and personal communication with the experts in this field. I have evaluated the outcome of studies to explore the causes of failure to achieve a positive result and to identify the positive gains of studies. Finally, I have compiled the positive gains to outline a new strategy for future study and greater achievement. The findings of evaluation led to the conclusion that while planning for initiation of CRRT, multiple strategies should be targeted. The strategy should involve early initiation of CRRT guided by new markers of acute kidney injury (AKI), continuous venovenous hemofiltration (CVVH) modality, optimum intensity (intensity should be adequate enough to improve hemodynamics within a targeted period), selection of an effective filter membrane. Elderly patients should be studied in a different group. Cardiac patients with AKI should not be studied in the same group along with the patients with sepsis.

The effects of refractoriness heart failure with renal insufficiency by continuous hemofiltratton / 中国实用内科杂志

Objective To investigate the effects and safety of the treatment of continuous veno-venous hemofiltration (CVVH)in refractoriness heart failure with renal insufficiency patients.Methods 35 hospitalized patients of refractori- ness heart failure with renal insufficiency were chosen from 2001 to 2006,25 patients were treated by CVVH,and other 10 patients were treated by regular hemodialysis.The serum BUN,Cr,left ventricle ejection fraction(LVEF),were observed before and after the therapy in each group.Results The clinical symptom were obviously improved in Group HF,and LVEF,cardiac output(CO) were both increased by continuous hemofiltration treatment(P

Treatment of sequential purification in rescuing acute grave intoxication:a report of 28 cases / 重庆医科大学学报

Objective:To investigate the therapeutic effect of sequential blood purification on rescuing acute grave intoxication.Methods:Twenty eight patients with acute intoxication were treated by HP+CVVH during 2002 and compared them with thirty patients without hemopurgation from 1998 to 2002.Results:The group of hemopurgation was better than non-hemopurgation group in the time of revive,the rate of recovery and death,and the total dose of atropine.Conclusion:Hemopurgation has decisively effect on rescuing all kinds of intoxication with toxins and drugs.It could quickly ameliorate symptom,raise success rate and reduce mortality;Hp combining with CVVH are suitable for the patients with toxicsis who had cardiac and respiratory failure,brain edema,and dielectric disorder.

Temporary Veno-venous Hemofiltration (TVVH) Using Low Flux Hemodialyzers / 대한신장학회잡지

BACKGROUND: Continuous veno-venous hemofiltration (CVVH) is one of the continuous renal replacement therapies for managing patients with refractory edema or oliguric renal failure with unstable vital signs. High-flux hemofilters are usually used for CVVH, but low-flux hemodialyzers are not used for CVVH. We tried temporary veno-venous hemofiltration (TVVH) procedures using low-flux hemodialyzers for 9 patients with acute or chronic renal failure who were on mechanical ventilation with positive end-expiratory pressure (PEEP) in the ICU. METHODS: All of the nine patients with acute or chronic oligo-anuric renal failure could not receive hemodialysis treatment in the hemodialysis room, because they were on mechanical ventilation with PEEP in the ICU due to severe fluid overload with elevated CVP and acute pulmonary edema. Low-flux hemodialyzers with effective membrane area of 1.0- 1.1 m2 and blood pumps on the discarded hemodialysis machines were used for TVVH procedures. RESULTS: Mean duration of TVVH was 17.0+/-16.7 hours and mean ultrafiltration rate was 440+/-203 mL/hour. After finishing the TVVH procedures, CVP decreased from 22.9+/-8.5 cmH2O to 6.4+/-2.4 cmH2O. Of nine patients, 6 patients (67%) were able to be off the mechanical ventilation with clinical improvement. CONCLUSION: Even if CVVH is usually done with expensive high-flux hemofilters and CVVH machines, simplified and cheaper TVVH procedures using low- flux hemodialyzers and discarded hemodialysis machines with functioning blood pumps can be done with good results and cost effectiveness, especially in institutions not equipped with facilities such as CVVH machines or portable water purification systems for hemodialysis in the ICU.

The Clinical Characteristics of Patients Treated with Continuous Renal Replacement Therapy / 대한신장학회잡지

PURPOSE: Continuous renal replacement therapy (CRRT) has been developed and it has advantages, although the patients receiving CRRT still have a high mortality. This study was designed to compare the clinical characteristics of patients treated with CRRT between survivors and non-survivors. METHODS: From May 1992 to February 2000, continuous venovenous hemofiltration(CVVH) treatment was applied to 51 patients. Underlying disease, duration of CVVH treatment, blood pressure before and after the treatment were reviewed and APACHE III score, number of organ failures, blood pressure at the begining were compared between two groups. RESULTS: The average age was 56.3+/-5.6 years and the mortality was 86.3%(44 patients). The comorbid conditions were sepsis(66.7% of total patients), hepatic failure(33.3%), congestive heart failure(17.6%) and adult respiratory distress syndrome(9.8%). Mean arterial pressure(MAP) at the begining was 66.9+/-9.7 mmHg and MAP 2 hours after the treatment was 59.3+/-1.5 mmHg(p=0.076). APACHE III score was 59.5+/-3.5 in non-survivors and 56.0+/-0.9 in survivors and mean number of organ failures was 2.63+/-.98 in non-survivors and 1.68+/-.34 in survivors, but there was no difference between two groups(p=0.072). MAP at begining was significantly higher in survivors than that of non-survivors(87.86+/-3.15 vs. 63.49+/-7.04)(p=0.002). CONCLUSION: Most of the patients receiving CVVH have more than two organ failures. There were no significant difference in the number of organ failures and APACHE III score between survivor group and non-survivor group. It may be due to underlying disease of patients that MAP at the begining was lower in non-survivors than survivors. APACHE III score would not be a good prognostic predictor.

Daytime Intermittent Venovenous Hemofiltration(IVVH) for the Treatment of Refrctory Edema / 대한신장학회잡지

BACKGROUND: Refractory edema in some patients with advanced heart failure or renal failure will not respond to diuretic therapy. In this setting, the ex- cess fluid can be removed by continuous hemofiltration either by continuous arteriovenous hemofiltration (CAVH) or continuous venovenous hemofiltration (CVVH). Careful monitoring is required to prevent life-threatening hypotension due to continued production of large ultrafiltrate. To overcome these disadvantages of CVVH, we attempted to perform daytime 1VVH as an alternative therapeutic modality to CVVH. METHODS: We performed venovenous hemofiltration for eight hours in the daytime in dialysis unit and repeated intermittently at 1 or 2 days interval if further treatment is required. We called this intermittent venovenous hemofiltration(IVVH). From October 1992 through November 1997, we prospectively studied the efficacy and usefulness of IVVH in 42 patients with refractory edema. RESULTS: Underlying disorders which required IVVH were renal insufficiency in 28 patients and nephrotic syndrome in 14 patients. The mean duration of treatment was 17.0+/-8.4 hours. Total UFR was 26.1+/-153L and mean UFR/hr was 1.5+/-2.2L. Edema was successfully controled with only one time treatment of IVVH in 12(28.6%), two in 17(40.5%), three in 7(16.6%), four in 4(9.5%), and five in 2(4.8%), Mean number of IVVH treatments per patient was 2.2+/-0.4 to complete the treatment of refractory edema. Changes in blood chemistry and hemodynamics before and after IVVH were not significantly different. Body weight and abdominal girth decreased significantly after IVVH(p<0.001). No major complications occurred during these trials. There were only two episodes(5.1%) of transient hypotension, and each one episode(2.6%) of bleeding at access site and arrhythmia, respectively. CONCLUSION: These results stongly suggest that IVVH is a simple, safe and effective method in the treatment of refractory edema not responding to diuretic therapy.

Successful Repair of Postoperative Left Ventricular Rupture following Mitral Valve and Aortic Valve Replacement with Tricuspid Valve Annuloplasty in Chronic Renal Failure / 日本心臓血管外科学会雑誌

Left ventricular rupture is one of the major lethal complications of mitral valve replacement. A case of successful repair of postoperative left ventricular rupture following mitral valve and aortic valve replacements, tricuspid valve annuloplasty in chronic renal failure is described. The patient was a 58-year-old male and suffered from mitral stenosis and regurgitation with left atrial thrombi, aortic stenosis and regurgitation, and tricuspid regurgitation. It has been 13 years since the patient was operated on for mitral stenosis with open mitral commissurotomy. Mitral valve and aortic valve replacements, tricuspid valve annuloplasty was performed under cardiopulmonary bypass and cardioplegic arrest using the extracorporeal ultrafiltration method (ECUM) and continuous venovenous hemodialysis (CVVH). The patient has been in good condition during weaning from cardiopulmonary bypass. After the operation, left ventricular rupture occurred due to transient high blood pressure in the operating room. The patient was quickly put back on cardiopulmonary bypass. In this case, the rupture occurred although no technical errors were thought to be made. The site of the rupture was type II in the Treasure classification. The left ventricular rupture was repaired with the patch closure method under cardiopulmonary bypass and cardioplegic arrest. The postoperative cardiac function was relatively well preserved. More attention should be paid to cases in this type of condition; mitral stenosis, long history, multiple valve replacements, and chronic renal failure. This patient died from sepsis caused by the infectious route of continuous ambulatory peritoneal dialysis (CAPD) on the 61st postoperative day.