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Saudi Journal of Kidney Diseases and Transplantation
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Year : 1998  |  Volume : 9  |  Issue : 3  |  Page : 294-297
Slow Continuous Ultrafiltration with Dialysis in Patients with Acute Renal Failure in the Intensive Care Unit


Department of Nephrology, Jeddah Kidney Center, King Fahad Hospital, Jeddah, Saudi Arabia

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How to cite this article:
Shaheen FA, Sheikh IA. Slow Continuous Ultrafiltration with Dialysis in Patients with Acute Renal Failure in the Intensive Care Unit. Saudi J Kidney Dis Transpl 1998;9:294-7

How to cite this URL:
Shaheen FA, Sheikh IA. Slow Continuous Ultrafiltration with Dialysis in Patients with Acute Renal Failure in the Intensive Care Unit. Saudi J Kidney Dis Transpl [serial online] 1998 [cited 2019 Apr 26];9:294-7. Available from: http://www.sjkdt.org/text.asp?1998/9/3/294/39273

   Introduction Top


In a tertiary referral hospital, the consultant nephrologist on-call receives an average of two to three consultations daily from intensive care units (ICU) for the management of patients with acute renal failure (ARF). Our experience shows that about 25% of these patients require some form of renal replace­ment therapy (RRT). The choice between the different modalities of RRT depends on the individual patient's condition and the experience of the treating physician. Continuous renal replacement therapy (CRRT) has been used in ARF for the last two decades besides conventional hemodialysis and peritoneal dialysis [1] .


   Continuous Renal Replacement Therapy (CRRT) Top


The procedures of CRRT are named according to the type of blood access used and whether dialysate is being used or not. In some modalities, solutes and water is removed by convection only, while in others the solute is removed by diffusion, which is comparable to the conventional hemodialysis.

Continuous arteriovenous hemofiltration was the simplest early procedure, which was intended for removal of fluids [1] . In 1984, dialysate was added to the procedure for solute clearance [2] . At present, there is a list of procedures available and the names are almost self-explanatory. The different choices are listed in [Table - 1].

Many of the procedures of CRRT are similar with small difference in the technique and the type of the dialyzer used. The addition of dialysate makes the procedure more efficient for solute removal. In our experience, slow continuous ultrafiltration for ten hours with hemodialysis shows about 20% reduction in the pre procedure values.

The commonest practice in our ICU is the use of slow continuous ultrafiltration with hemodialysis (SCUF-HD) for patients with acute renal failure. The major disadvantage with the use of conventional hemodialysis in critically ill patients is the high probability of circulatory collapse with quick removal of solute and fluid. This complication can be avoided by the use of continuous renal replacement therapy (CRRT). However, it should be stressed that some of the CRRT procedures are capable of removal of large quantities of fluid over short periods if blood-flow-pumps and dialyzers with large surface area are used.

Some patients admitted to ICUs have profound septicemia leading to septic shock and acute renal failure. The mortality rate may reach 100% in this group of patients [3] .

The immunomodulatory substances like tumor necrosis factor, Platelet activating factor and endotoxins cause myocardial depression. These toxins are not removed by conventional hemodialysis [4],[5] . There is some evidence from studies that hemo­filtration is effective in removing these substances, thereby positively influencing the survival of these patients [6],[7] . We have found the use of CVVH and CVVHD effective in patients with acute renal failure [8] . The main indications are mentioned in [Table - 2]. We will highlight the importance of SCUF-HD for patients with acute renal failure in ICU.


   Slow Continuous Ultrafiltration with Hemodialysis (SCUF-HD) Top


Until recently, the most accepted modality in our unit was continuous venovenous hemofiltration but this required a costly set of tubing with special hemofilter. Considering the number of patients and the cost effective­ness, a pilot study was designed to estimate the clearance performed by SCUF-HD with the use of low or medium flux dialyzers. The results of this study were encouraging. The hourly blood chemistry and blood count revealed significant solute clearance without significant side effects. Blood flow of about 100 ml/min and dialysate flow around 1.5 liter/hour proved sufficient [9] . There was a 20% reduction in blood urea and creatinine levels after 10 hours of SCUF-HD. We maintained a blood flow of 80 ml/min and a dialysate flow of 1 liter/hr. The advantage of this procedure was that the ultrafiltrate was typically low which was helpful in keeping the patient's vital signs stable. We have also tried a 24 hour SCUF-HD for many end stage renal disease patients, who were admitted to ICU for other problems, and in our experience, the amount of treatment they received was sufficient.


   Procedure Top


A double lumen catheter is inserted into the subclavian, internal jugular or femoral veins for vascular access. A dual pump machine is used. One pump is used to control the blood flow to the dialyzer while another pump is used to monitor the dialysate flow rate. Heparin pump is introduced before blood enters the dilayzer. The dialysate flows opposite to the direction of flow of blood and is drained out to a bag along with the ultrafiltrate. The replacement fluid can be added in the line returning back to the venous side of the double lumen catheter.

We have used hollow fiber-dialyzer with a surface area of 1.0 M for adult patients. This is the same dialyzer, which we use in our routine conventional hemodialysis.

In the beginning, the dialysate flow was kept around 500 ml/hr. However, to get better clearance of middle molecular weight toxins, we increased the dialysate flow to 1000 ml/hr. The dialysis solution is prepared locally or, in emergencies, we have used 1.5% peritoneal dialysis solution.

Heparin is used routinely as an anticoagulant. We have found 500 I.U. per hour usually sufficient after initial rinsing of lines and dialyzers with 2000 Units of heparin. Close monitoring of the coagulation profile is mandatory. Regional heparinization is practiced if the patient has a bleeding tendency.

The ultrafiltrate in this procedure is appro­ximately 5-7 liter/24 hours, and it can be replaced in the venous line hourly. We have used dextrose 5% normal saline or Ringer's solution as replacement fluid.


   Advantages Top


With the use of low flux dialyzers and locally prepared dialysate, we have been able to reduce the cost of the procedure. The SCUF-HD has been in regular use in our center for more than four years with excellent results providing sufficient therapy in acute as well as sick chronic dialysis patients. Complications, such as circulatory collapse and blood clotting in dialyzers are minimal.


   Comment Top


Slow continuous ultrafiltration has been the modality of choice for slow removal of fluid with no significant expected clearance. The use of low flux dialyzer and dialysate (SCUF-HD) proved to have good clearance of urea, creatinine and potassium. Until now, over 300 patients have undergone this procedure and our staff is well trained to perform this mode of CRRT. The procedure seems to be very much similar to CVVHD but the main differences are a low ultrafiltrate, use of a normal dialyzer and good clearance of toxins. We have adopted this procedure for a smooth effective dialysis treatment in critically ill patients in intensive care unit with acute or chronic renal failure.

 
   References Top

1.Kramer P, Wigger W, Rieger J, Matthaei D, Scheler F. Artcriovenous haemofiltration and simple method for treatment of over hydrated patients resistant to diuretic. Klinwochenschr 1977;55:1121-2.  Back to cited text no. 1    
2.Geronemus R, Schneider N. Continuous arteriovenous hemodialysis: a new modality for treatment of acute renal failure. Trans Am Soc Artif Intern Organs 1984;30:610-3.  Back to cited text no. 2  [PUBMED]  
3.Spiegel DM, Ullian ME, Zerbe GO, Berl T. Determinants of survival and recovery in acute renal failure patients dialyzed in intensive-care units. Am J Nephrol 1991;11:44-7.  Back to cited text no. 3  [PUBMED]  
4.Ronco C.Continuous renal replacement therapies for the treatment of acute renal failure in intensive care patients. Clin Nephrol 1993;40:187-98.  Back to cited text no. 4  [PUBMED]  
5.Moldawer LL. Interleukin-1, TNF alpha and their naturally occurring antagonists in sepsis. Blood Purif 1993;11:128-33.  Back to cited text no. 5  [PUBMED]  
6.Hoffmann JN, Haiti WH, Deppisch R, et al. Hemoflltration in human sepsis: evidence for elimination of immunomodulatory substances Kidney Int 1995;48:1563-70.  Back to cited text no. 6    
7.Stein B, Pfenninger E, Grunert A, Schmitz JE, Hudde M. Influence of continuous haemofiltration on haemodynamics and central blood volume in experimental endotoxic shock. Intensive Care Med 1990;16:494;9.  Back to cited text no. 7    
8.Shaheen FAM, Sheikh IA, Souqiyyeh MZ. Continuous arteriovenous and continuous venovenous hemodialysis. Saudi J Kidney Dis Transplant 1994;5(3):379-83.  Back to cited text no. 8    
9.Sigler MH, Teehan BP. Solute transport in continuous hemodialysis: a new treatment for acute renal failure. Kidney Int 1987;32:562.  Back to cited text no. 9  [PUBMED]  

Top
Correspondence Address:
Faissal A.M Shaheen
Director & Consultant Nephrologist, Jeddah Kidney Center, King Fahad Hospital, P.O. Box 11076, Jeddah 21453
Saudi Arabia
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PMID: 18408303

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    Introduction
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    Slow Continuous ...
    Procedure
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