Dose of dialysis in acute renal failure

Abstract

Acute renal failure (ARF) is a cause of significant morbidity and mortality. Despite advances in supportive care, outcomes in ARF have improved little over the past decades. The primary goals in management of patients with ARF are to optimize hemodynamic and volume status, minimize further renal injury, correct metabolic abnormalities, and permit adequate nutrition. Renal replacement therapy (RRT) is often required to achieve these goals while awaiting renal recovery, but the optimal dose of dialysis in patients with ARF is not known. Extrapolation of required dialysis dose from recommendations in chronic dialysis is unlikely to be appropriate because of the lack of a steady state and differences in distribution volume of urea that are intrinsic to ARF. The prescribed dialysis dose in ARF is often low, and actual delivered dose is often even less than prescribed. Delivery of dialysis in ARF is often hampered by the patient's hypercatabolic state, hemodynamic instability, and volume status, as well as suboptimal vascular access with temporary venous catheters. The impact of intermittent hemodialysis (IHD) versus continuous renal replacement therapy (CRRT) on outcomes in ARF is also not clear. Patient disease severity impacts more than dialysis modality in patient outcome, but when patients are stratified for equal disease severity, CRRT may have potential benefits over IHD in terms of patient survival, fluid and metabolic control, and renal recovery. Strategies associated with improved outcomes that have emerged thus far in ARF are to aim for a time-averaged blood urea nitrogen (BUN) of less than 60 mg/dl with IHD, varying IHD frequency as necessary, or to achieve a minimum ultrafiltration rate of 35 ml/kg/hr with CRRT.