Romero-González, G. (Vicenza/Medellín); Lorenzin, A.; Neri, M.; Ferrari, F. (Vicenza); Molano-Triviño, A. (Vicenza/Bogotá); Brendolan, A.; Ronco, C. (Vicenza)
Ensuring Quality of Care through Monitoring of Continuous Renal Replacement Therapies
Rosner, M.H. (Charlottesville, VA)
Continuous Renal Replacement Therapy Quality Control and Performance Measures
Shen, B.; Xu, J.; Wang, Y.; Jiang, W.; Teng, J.; Ding, X. (Shanghai)
Goldstein, S.L. (Cincinnati, OH)
From Continuous Renal Replacement Therapies to Multiple Organ Support Therapy
Ricci, Z. (Rome); Romagnoli, S. (Florence); Ronco, C. (Vicenza); La Manna, G. (Bologna)
Forty years ago, Peter Kramer in Gottingen treated the first patient with continuous arterio-venous hemofiltration. Such techniques represented the real alternative for those patients in which hemo or peritoneal dialysis were precluded or contraindicated. Continuous arterio-venous hemofiltration was the first of several other techniques subsequently called continuous renal replacement therapies (CRRT). In this time frame, we can identify 4 different decades: the first was dedicated to the exploration and development of this new therapeutic approach; the second was characterized by the birth of a new specialty called critical care nephrology; the third decade was the time of new devices and machines specifically designed for CRRT; and the last decade was mainly characterized by the interaction that took place among different specialists who recognized the utility of extracorporeal therapies for multiple organ support and sepsis. Many of the advances in this field are linked to the results of the consensus conferences of the Acute Disease Quality Initiative group. Forty years later, we have new machines and new techniques that are the result of a long history of developments, studies, and practices. It is the right time to make an appraisal of CRRT and its role in the management of the critically ill patient with acute kidney injury as a celebration of an important moment of critical care nephrology. We decided to make this 40-year anniversary book as a volume of the series “Contributions to Nephrology,” since Karger has graciously accepted to publish it with accuracy and care. The content of this book features contributions from prominent CRRT experts from all over the world. This book represents an important tool for educating a new generation of nephrologists and intensivists, while at the same time providing the most advanced CRRT users with the latest technological information, the most updated clinical evidence, and the personal opinion of key leaders who contributed to make the last 40 years of history in the field.
Claudio Ronco, Vicenza
Rinaldo Bellomo, Melbourne, VI
John A. Kellum, Pittsburgh, PA
Gaetano La Manna, Bologna
Bellomo R, Kellum JA, La Manna G, Ronco C (eds): 40 Years of Continuous Renal Replacement Therapy.
Contrib Nephrol. Basel, Karger, 2018, vol 194, pp 1–14 (DOI: 10.1159/000485596)
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Evolution of Technology for Continuous Renal Replacement Therapy: Forty Years of Improvement
Claudio Ronco
Department of Nephrology, Dialysis and Transplantation, International Renal Research Institute of Vicenza (IRRIV), St. Bortolo Hospital, Vicenza, Italy
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Abstract
Continuous arteriovenous hemofiltration (CAVH) was proposed in 1977 as an alternative treatment for acute renal failure in patients in whom peritoneal dialysis or hemodialysis was clinically or technically precluded. In the mid-1980s, this technique was extended to infants and children. CAVH presented important advantages in the areas of hemodynamic stability, control of circulating volume, and nutritional support. However, there were serious shortcomings such as the need for arterial cannulation and limited solute clearance. These problems were solved by the introduction of continuous arteriovenous hemodiafiltration and continuous arteriovenous hemodialysis, where uremic control could be achieved by increasing countercurrent dialysate flow rates to 1.5 or 2 L/h as necessary, or by venovenous techniques utilizing a double-lumen central venous catheter for vascular access. Thus, continuous venovenous hemofiltration replaced CAVH because of its improved performance and safety. From the initial adoptive technology, specific machines have been designed to permit safe and reliable performance of the therapy. These new machines have progressively undergone a series of technological steps that have resulted in the evolution of highly sophisticated equipment utilized today. A significant number of advances have taken place since the time continuous renal replacement therapy was initiated. In particular, there have been successful experiments with high-volume hemofiltration and high-permeability hemofiltration. The additional and combined use of sorbent has also been tested successfully. Progress has been made in the technology as well as the understanding of the pathophysiology of acute kidney injury. Today, new biomaterials and new devices are available and new frontiers are on the horizon. Although improvements have been made, a lot remains to be done. Critical care nephrology is expected to further evolve in the near future, especially in the area of information and communication technology, utilization of big data and large database registries, biofeedback, and assisted prescription and treatment delivery, with high potential for improvement in morbidity and mortality of the most severely ill patients.
© 2018 S. Karger AG, Basel
Introduction
Acute kidney injury (AKI) is an important syndrome frequently occurring in intensive care patients with high morbidity and mortality. This clinical entity has required a progressive scientific effort to develop adequate technology for providing safe and reliable treatment. As a consequence, the area of acute renal replacement therapy (RRT) and related technology underwent a significant evolution over the last 4 decades, making critical care nephrology a new emerging subspeciality of intensive care medicine [1, 2]. We briefly describe the pathway of evolution in the area of continuous RRT (CRRT) that has occurred over the last 40 years.
The Era of Continuous Arteriovenous Hemofiltration
Continuous arteriovenous hemofiltration (CAVH) was first proposed in 1977 and immediately became an important alternative treatment for AKI in patients in whom peritoneal dialysis or hemodialysis was clinically or technically precluded [3]. This opened the doors of intensive care units to extracorporeal treatments, which experienced a flourishing evolution in subsequent years. In the mid-1980s, the technology of CAVH was extended to infants and children, and newly designed hemofilters permitted the application of the technique even to newborns [4].