ABSTRACT

The primary aims of any dialysis therapy used in the acute renal failure (ARF) setting are minimizing patient intolerance and providing treatment adequacy. With respect to patient tolerance, hemodynamic stability1 and a minimized inflammatory response due to interaction between the patient and the dialysis system2 are the most important considerations. However, the factors influencing acute dialytic treatment adequacy are relatively poorly understood and, as opposed to chronic dialysis therapy,3 the concept of treatment dose is not yet established firmly. Due to the complexity of the critically ill ARF patient, toxin removal, volume control, control of metabolic derangements, and nutritional provision may all influence treatment adequacy in acute dialysis.4-8

It is only recently that the nephrology community has begun to make a serious attempt to differentiate between the renal replacement needs of ARF patients and patients with end-stage renal disease (ESRD).9 For example, the indications for initiation of acute dialysis therapy may differ significantly from those used in the ESRD setting.10 In addition, that the management of the ARF patient with intermittent hemodialysis (IHD) cannot simply mimic the approach used for chronic HD patients is being acknowledged increasingly, along with the realization that dialytic requirements with respect to both solute and volume removal are significantly greater in the acute setting.11 Indeed, for the typical scenario of ARF in the context of multi-organ failure, traditional therapies used in the ESRD setting such as HD (especially performed only thrice-weekly) and peritoneal dialysis may not be feasible or even contraindicated, based on physiologic and metabolic considerations.12 Unlike the typical ESRD patient, patients with ARF are not at steady state and are unlikely to achieve acceptable azotemic control with a traditional thriceweekly IHD schedule or peritoneal dialysis.13