Brain density changes during renal replacement in critically ill patients with acute renal failure. Continuous hemofiltration versus intermittent hemodialysis

Abstract

Computerized tomography (CT) studies of the brain were made on 12 patients with acute renal failure from different origin. Patients were treated for two subsequent days in random sequence with intermittent hemodialysis (HD) (one 4-h session and Kt/V > or = 1) and continuous veno-venous hemofiltration (CVVH) (one 24-h session and Kt/V > or = 1). CT scans were done before and after the HD and CVVH session in each patient. In baseline conditions, the only macroscopic morphological alteration was a slight brain edema in some patients. Significant changes in the density of white and gray matter were observed after the HD session in all patients (gray matter from 52.3 +/- 5.2 to 38.9 +/- 5.3 and white matter from 36.7 +/- 3.5 to 24.8 +/- 3.2 Hounsfield units, average delta -26.7%). No changes were observed after CVVH. We conclude that intermittent HD involves a remarkable degree of "unphysiology", leading to increased water content in the brain after each session. In acute patients this may lead to a post-dialytic brain edematogenic state. The physiological stability provided by continuous therapies such as CVVH avoids this unwanted effect, and suggests that continuous renal replacement therapies should be a first choice in these patients.