Renal replacement therapy

Dosing of Selected Intravenous Anti-Infectives in Patients Receiving Continuous Renal Replacement Therapy... 

Refer the patient to a nephrologist to manage complications associated with CKD. As CKD progresses to stage 4, begin discussion to prepare the patient for renal replacement therapy. 

Fluid restriction is generally unnecessary as long as sodium intake is controlled. The thirst mechanism remains intact in CKD to maintain total body water and plasma osmolality near normal levels. Fluid intake should be maintained at the rate of urine output to replace urine losses, usually fixed at approximately 2 L/day as urine concentrating ability is lost. Significant increases in free water intake orally or intravenously can precipitate volume overload and hyponatremia. Patients with stage 5 CKD require renal replacement therapy to maintain normal volume status. Fluid intake is often limited in patients receiving hemodialysis to prevent fluid overload between dialysis sessions. 

Patients who progress to ESRD require renal replacement therapy (RRT). The modalities that are used for RRT are dialysis, including HD and peritoneal dialysis (PD), and kidney transplantation. The United States Renal Data Service (USRDS) reported that the number of patients with ESRD was 452,957, with 102,567 new cases being diagnosed in 2003.2 The most common form of RRT is dialysis, accounting for 72% of all patients with ESRD. The principles and complications associated with dialysis are discussed below. Chapter 52 discusses the principles of kidney transplantation. 

What alternatives for renal replacement therapy exist for the patient ... 

Establish if the patient requires renal replacement therapy. 

Renal replacement therapy (RRT), such as hemodialysis and peritoneal dialysis, maintains fluid and electrolyte balance while removing waste products. See Table 75-4 for indications for RRT in ARF. Intermittent and continuous options have different advantages (and disadvantages) but, after correcting for severity of illness, have similar outcomes. Consequently, hybrid approaches (e.g., sustained low-efficiency dialysis and extended daily dialysis) are being developed to provide the advantages of both. 

After regimen changes and after renal replacement therapy has been instituted Daily Daily... 

Continuous renal replacement therapy is used for the management of fluid overload and removal of uremic toxins in patients with acute renal failure and other conditions. Drug therapy individualization for patients receiving continuous renal replacement therapy is discussed in Chap. 75. 

Collidge TA, Thomson PC, Mark PB, Traynor JP, Jardine AG, Morris ST, Simpson K, Roditi GH (2007) Gadolinium-enhanced MR imaging and nephrogenic systemic fibrosis retrospective study of a renal replacement therapy cohort. Radiology 245 168-175. 

Bohler J, Donauer J, Keller F. Pharmacokinetic principles during continuous renal replacement therapy drugs and dosage. Kidney Int 1999 72 Suppl S24-8. 

Subach RA, Marx MA. Drug dosing in acute renal fail-ure the role of renal replacement therapy in altering drug pharmacokinetics. Adv Renal Repl Ther 1997 5 141-7. 

A 57-year-old man developed renal insufficiency after triple coronary bypass grafting, 7 days after povidone-iodine mediastinal irrigation and required 3 days of renal replacement therapy (21). Complete resolution... 

Five patients with metformin-associated severe lactic acidosis, seen between 1 September 1998 and 31 May 2001, have been reported (58). Two had attempted suicide. All had severe metabolic acidosis with a high anion gap and raised blood lactate concentrations. Four developed profound hypotension and three had acute respiratory failure. Three had normal preceding renal function. Three required conventional hemodialysis and two continuous renal replacement therapy. 

A 59-year-old obese woman with normal renal function, taking metformin 500 mg tds, took orlistat 120 mg tds for 3 months (147). She developed abdominal pain and diarrhea, for which she was given cimetidine, and became weak and dizzy, with blurred vision, reduced consciousness, agitation, and confusion. Her pH was 6.5, bicarbonate 2 mmol/1, base deficit 38 mmol/1, and lactate 21 mmol/1. She required rehydration, bicarbonate, inotropic support and renal replacement therapy. 

Congenital nephrotic syndrome of the Finnish type is clinically characterized by heavy proteinuria present already in utero, which leads without nephrectomy and renal replacement therapy to the death of the affected children usually before the second year of life. Electronoptically, the glomerular basement membrane seems to be intact with the fusion of the podocyte foot processes. The chemical composition of the glomerular basement membrane is normal in patients with congenital nephrotic syndrome and all genes of the main proteins of the glomerular... 

There is no actual treatment per se for acute renal failure. Just provide supportive measures, for example, renal replacement therapy (dialysis), treat the symptoms, and if possible, the underlying cause, and wait to see if renal function is recovered. 

Times of administered doses Doses relative to administration of renal replacement therapy Urinalysis... 

PATIENTS RECEIVING CONTINUOUS RENAL REPLACEMENT THERAPY... 

Preprinted order set design Hypokalemia Sliding scale insulin Continuous renal replacement therapy... 

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