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CHAPTER 99: Electrolyte Disorders in Critical Care 943

Removal of cytokines in the setting of sepsis and AKI via hemadsorp- • Mehta RL, McDonald B, Gabbai FB, et al. A randomized clinical
tion (coupled with hemofiltration) has been demonstrated as feasible trial of continuous versus intermittent dialysis for acute renal fail-
and effective at improving hemodynamics and survival in animal ure. Kidney Int. 2001;60:1154-1163.
studies. 93,94 Similarly, high cutoff hemofiltration (HCO) has demonstrated
effectiveness in clearance of cytokines and improving hemodynamics • Morgera S, Slowinski T, Melzer C, et al. Renal replacement therapy
in sepsis and AKI in both animal and human studies. However, more with high cut-off hemofilters: impact of convection and diffu-
effective removal of cytokines was complicated by removal of albumin as sion on cytokine clearances and protein status. Am J Kidney Dis.
well, questioning the relative risk versus benefit of HCO and highlight- 2004;43:444-453.
ing the need for future investigation. 95,96,97 • Parienti J, Thirion M, Megarbane B, et al. Femoral vs jugular
The RAD represents the most advanced form of RRT that truly venous catheterization and risk of nosocomial events in adults
attempts to mimic renal “replacement.” Nonautologous cultured tubular requiring acute renal replacement therapy: a randomized con-
cells grown along the inner surface of hollow fibers are placed in series trolled trial. JAMA. 2008;299:2413-2422.
with a conventional RRT circuit. The ultrafiltrate is pumped through • The RENAL Replacement Study Investigators. Intensity of contin-
the RAD allowing the renal cells to emulate their native functions. uous renal replacement therapy in critically-ill patients. N Engl J
Animal data suggested its potential benefit and human studies have Med. 2009;361:1627-1638.
demonstrated not only safety, but also preliminary efficacy. Specifically, • Trotman RL, Williamson JC, Shoemaker M, Salzer WL. Antibiotic
a phase II, randomized controlled trial of CRRT with the RAD versus dosing in critically ill adult patients receiving continuous renal
conventional CRRT alone demonstrated improved survival and renal replacement therapy. Clin Infect Dis. 2005;41:1159-1166.
recovery. Forty patients were assigned to CRRT plus the RAD and
18 patients were assigned to conventional CRRT. Renal recovery • Uchino S, Kellum JA, Bellomo R, et al. Acute renal failure in
and overall 28- and 180-day survival was better in the RAD group critically ill patients: a multinational, multicenter study. JAMA.
compared with the conventional CRRT group. However, a subsequent 2005;294(7):813-818.
98
phase IIb trial was unsuccessful, and development efforts continue. • Udy AA, Baptista JP, Lim NL, et al. Augmented renal clearance
99
in the ICU: results of a multicenter observational study of renal
CONCLUSION function in critically ill patients with normal plasma creatinine
concentrations. Crit Care Med. 2014;42(3):520-527.
We have made significant progress in making RRT more accessible to • VA/NIH Acute Renal Failure Trial Network. Intensity of renal
the critically ill. Increased overall collaboration between intensivists and support in critically ill patients with acute kidney injury. N Engl J
nephrologists has increased access to RRT and increased the potential Med. 2008;359:7-20.
for better outcomes in critically ill individuals with AKI requiring RRT.
Large, coordinated investigative efforts have allowed the critical care • Vinsonneau C, Camus C, Combes A, et al. Continuous venovenous
hemodiafiltration versus intermittent hemodialysis for acute renal
nephrology community to reach some important conclusions: (1) there
is a minimal, acceptable dose of RRT in AKI, but more intense CRRT failure in patients with multiple-organ dyfunction syndrome: a
multicenter randomized trial. Lancet. 2006;368:379-385.
or daily IHD does not improve outcomes for all patients and (2) CRRT
is not superior to IHD in many AKI cases, and IHD can be safely • Wald R, Shariff SZ, Adhikari NK, et al. The association between
performed on many critically ill patients with multiorgan system failure. renal replacement therapy modality and long-term outcomes
Nevertheless, we have significant room for improving our understand- among critically ill adults with acute kidney injury: a retrospective
ing of the application of RRT to critically ill patients. Determining the cohort study. Crit Care Med. 2014;42(4):868-877.
optimal time point to initiate RRT and the best approach to adjusting
the dose of RRT to the underlying clinical environment remain two impor-
tant areas that require further investigation. Finally, we need to move REFERENCES
this field to the point where we are truly providing renal “replacement,”
accounting for innovative filter and circuit characteristics as well as Complete references available online at www.mhprofessional.com/hall
providing optimal supportive care including nutritional support and
appropriate medication adjustment. Once all of these components are
in place, patients may receive the maximal benefit of extracorporeal CHAPTER Electrolyte Disorders
support with fewer complications. in Critical Care
99
Caitriona McEvoy
Patrick T. Murray
KEY REFERENCES
• Augustine JJ, Sandy D, Seifert TH, Paganini EP. A randomized
controlled trial of intermittent with continuous dialysis with ARF. KEY POINTS
Am J Kidney Dis. 2004;44:1000-1007. • Measurement of electrolyte-free water clearance is extremely use-
• Bouchard J, Soroko SB, Chertown GM, et al. Fluid accumulation, ful in understanding the pathophysiology of hyponatremia and
survival and recovery of kidney function in critically ill patients hypernatremia.
with acute kidney injury. Kidney Int. 2009;76:422-427. • Treatment of hyponatremia should be guided by the degree of symp-
• Kutsogiannis DJ, Gibney RTN, Stollery D, Gao J. Regional citrate tomatology, rather than the magnitude of the hyponatremia per se.
versus systemic heparin anticoagulation for continuous renal • Hyperkalemia should be treated emergently if typical electrocar-
replacement in critically ill patients. Kidney Int. 2005;67:2361-2367. diographic (ECG) changes are present; hence, ECG monitoring is
• Lins RL, Elseviers MM, Van der Niepen P, et al. Intermittent indispensable in this setting
versus continuous renal replacement therapy for acute kidney • Hypocalcemia need only be treated urgently if it is symptomatic.
injury patients admitted to the intensive care unit: results
of a randomized clinical trial. Nephrol Dial Transplant. • Severe hyperphosphatemia is seen in the setting of renal failure
2009;24:512-518. and/or massive cell lysis.

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