The cornerstone of
renal replacement therapy in
critically ill patients with
acute renal failure (ARF) in our hospital, was intermittent
bicarbonate dialysis with synthetic membranes, prescribed daily for anuric patients. Filling of the extracorporeal circuit with 5%
human albumin or
saline solution before the start of dialysis, as well as hypernatraemic dialysis with profiling, lower
dialysate temperature and higher ionized
calcium concentration have been used to prevent harmful hypotensive episodes either at the start or during dialysis.
Continuous renal replacement therapy (CRRT) in adults was used primarily for anuric, hypotensive patients who might not tolerate standard haemodialysis. All newborns and infants in whom
peritoneal dialysis was not possible were treated by continuous procedures.
Sustained low efficiency dialysis (SLED) or
extended daily dialysis (EDD) were an acceptable compromise between intermitent haemodialysis and CRRT. However, in our opinion, the most promising approach to intensive care unit (ICU) patients with ARF would be the combination of CRRT in the anuric patient followed by intermittent daily dialysis thereafter. Although the mortality rate of ARF patients was as high as 88% in adults and 73% in small children due to the lack of reliable criteria for the selection of patients with poor or good prognosis, aggressive treatment for all patients who needed dialysis was recommended recently.
Apheresis has dramatically improved the prognosis and outcome in patients with
myasthenia gravis,
Guillain-Barré syndrome,
Goodpasture syndrome and
thrombotic thrombocytopenic purpura. The mortality rate of patients with
septic shock and
fulminant hepatic failure was still very high, and the role of
apheresis and dialysis, in spite of some encouraging results, remains controversial.