Garred LJ, Canaud B, Bosc JY, Leblanc M
Urea kinetic modeling for acute renal failure
43rd Annual ASAIO Conference, Atlanta
ASAIO J
(Apr) 43:71 1997
With all the work on dialysis adequacy in chronic renal failure, it is
surprising that the
only paper of note on adequacy in acute renal failure is by
Martine Leblanc and Emil Paganini and their colleagues . Garred
et al in this
abstract attempt to systematize the kinetics of ARF, using an approach that
measures both
time averaged urea concentration (TAC) and peak BUN (blood urea nitrogen)
concentrations.
For various levels of urea generation, and various intermittent dialysis
schedules (IRT)
and for continuous renal replacement therapy (CRRT), the effects of therapy
on TAC and
peak BUN were compared. It was found that CRRT and IRT had similar effects
on TAC urea,
but that peak BUN values were reduced using CRRT.
Comment: This is nice work, but it only theoretical. My own view is,
that neither
TAC nor peak BUN are very important in ARF. Otherwise, we are going back to
the days of
the National Cooperative Dialysis Study, when adequacy in chronic dialysis
was measured in
terms of TAC urea. I think (opinion, no evidence, now), that the single
greatest mistake
in treating ARF patients with minimal residual renal function is, to withhold
dialysis
based on a low value of the BUN. In my own practice, I have dialyzed on a
daily basis
patients in whom the BUN was only 40 mg/dl, and I am convinced that the
patients
benefitted from this intensive therapy (Kru, residual renal function was
measured and
found to be negligible in these patients). I predict that, just as in
chronic therapy,
where the move has been to give a similar, large, target dose of dialysis
regardless of
the protein catabolic rate, we will find that (1) intermittent dialysis works
just as well
as CRRT, but (2) we are grossly underdialyzing our patients with ARF using
IRT, and (3)
daily intermittent dialysis for patients with ARF and small amounts of
residual renal
function will become the norm (perhaps excluding Sundays). Unfortunately,
studies in ARF
patients are difficult to do, given the high expected mortality rate and the
legal climate
in the United States. (John T. Daugirdas, M.D., University of Illinois at
Chicago)
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43rd Annual ASAIO Conference, Atlanta
Basic hemodialysis :
(Intermittent) dialysis for ARF
Basic hemodialysis :
Adequacy, prescription, urea kinetics