02 Sperati Prevention And Management Of Acute Renal Failure


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  • Has mortality from acute renal failure decreased? A systematic review of the literature Yvonne Patricia Ympa MD a , Yasser Sakr MBBCh, MSc b , Konrad Reinhart MD, PhD b and Jean-Louis Vincent MD, PhD a , , a Department of Intensive Care, Erasme Hospital, Free University of Brussels, Belgium b Department of Anesthesia and Intensive Care, Friedrich Schiller University, Jena, Germany Available online 8 August 2005. Abstract Purpose To determine mortality rates in patients with acute renal failure during the past decades. Methods We performed a MEDLINE search using the keywords “acute renal failure” crossed with “outcome,” “mortality,” “ICU,” “critically ill” or “prognosis” in the period from January 1970 to December 2004. Abstracts and full articles were eligible if mortality rates were reported. We also reviewed the bibliographies of available studies for further potentially eligible studies. The dates of the observation period for each study and not the publication dates were considered for the analysis, so the earliest data were from 1956. Results Of 85 articles fulfilling the criteria, 5 were excluded because of duplicate publications using the same database, so that 80 were included in our review with a total of 15 897 patients. Mortality rates in most studies exceeded 30%, and there was no consistent change over time. Conclusion Despite technical progress in the management of acute renal failure over the last 50 years, mortality rates seem to have remained unchanged at around 50%.
  • Though vascular etiologies are generally prerenal like to separate them out from the usual algorithm above in order to not miss such diagnoses – renal artery stenoses and more ominously dissections or thromboses or emboli
  • Predialysis weight predicts Kt/V Interestingly, the major determinant of the Kt/V urea was the pre-dialysis weight. What that tells us -- and that is for both prescribed and delivered dose of dialysis - this tells us that we prescribe dialysis for our acute patients based more on logistics than on the patient that is in front of us. We tend to be limited by nursing staff availability and other procedures the patient may be going through, so we tend to prescribe a fixed dose of dialysis in terms of time, in terms of maximal achievable blood flow, no matter whether the patient in front of us weighs 50 kg or the patient in front of us weighs 100 kg, and no matter what the urea generation rate is of our patient.
  • Patients were randomly assigned ultrafiltration at 20 mL h(-1) kg(-1) (group 1, n=146), 35 mL h(-1) kg(-1) (group 2, n=139), or 45 mL h(-1) kg(-1) (group 3, n=140). The primary endpoint was survival at 15 days after stopping haemofiltration
  • Daily dialysis in ARF This was attempted to be exploited by a study published in The New England Journal by Dr. Schiffl with 172 patients; 160 randomized to daily dialysis versus every other day dialysis.
  • Equivalent renal urea clearance The issue that has come up lately in this is particularly relevant both in patients with end-stage renal disease and in patients with acute renal failure is that in addition to the intensity of a given dialysis session, the frequency with which your patient receives dialysis will make a substantial difference in the amount of solute clearance. Casino and Lopez published a number of years ago a concept for equivalent renal urea clearance. Dr. Gotch has done something similar with a standardized Kt/V urea. The concept is still the same with either type of format and that is that since removal of a solute such as urea is exponential during dialysis, most of the removal of the solute occurs relatively early in any given dialysis session when there is a greater concentration gradient from the blood to the dialysate So as one strives for ever greater Kt/V, let us say, in a given dialysis session one is proportionately removing less and less total amount of solute. So you will get more total solute removal by having frequent sessions, even at less individual intensity. For example here if we have an individual session Kt/V of 0.8 but we dialyze this patient seven times a week, we have an EKR clearance of 20 cc/minute per week. Whereas another patient if we choose to dialyze very intensively for a given session, let us say out here 1.8, but we only dialyze that patient two or three times a week, we will actually have less clearance. So you get much more solute clearance with increasing the frequency than necessarily with increasing the intensity of a given dialysis session. Nephrol Dial Transplant. 1996 Aug;11(8):1574-81. Related Articles, Links The equivalent renal urea clearance: a new parameter to assess dialysis dose. Casino FG, Lopez T. Department of Nephrology and Dialysis, Ospedale Civile, Matera, Italy. BACKGROUND: Currently the total (dialytic plus renal) urea clearance (KT) is computed as Kt/V plus the equivalent Kt/V (KT/VKR) provided by the renal urea clearance (KR). However, KT/VKR is computed with two different formulae, by Gotch and Keshaviah respectively. Moreover Teschan suggested a weekly KT, that is a multiple of Keshaviah's KT. We suggest the equivalent renal urea clearance (EKR), that kinetically quantifies the "time-averaged KT' and is independent of treatment type and schedule. METHODS: Computer simulation has been used to analyse the relationship between EKR, as corrected for urea volume (EKRc), and Kt/V. Data from 66 HD patients, of whom eight were on once-weekly and 11 on twice-weekly HD, had been used to compare EKR with current KTs. RESULTS: For each individual schedule, the relationship between EKRc and Kt/V is linear and each ml/min of KR increases EKR by the same amount. For instance, for thrice-weekly HD patients, EKRc = 1 + 10 x Kt/V: so that, the critical Kt/V values of 0.8 and 1.0 correspond to EKRc values of 9.0 and 11 ml/min respectively, independently from treatment type and schedule. As to the clinical data, all once- and twice-weekly patients had a significant KR and excellent clinical status, but most of them had 9 < or = EKRc < 11 ml/min. After appropriate reconciliation of units, it has been found that kinetic KT was overestimated by about 10-12% (range, 2-23%) by Keshaviah and Teschan's KT, and by about 2-7% (range, 0.3-15%) by Gotch's KT. CONCLUSIONS: EKRc can account for KR and provide guidelines for all types of dialysis treatments: as far as urea is concerned, dialysis adequacy should require EKRc > or = 11 ml/min. However, it is likely that EKRc > or = 9 ml/min could suffice for patients with a substantial residual renal function.
  • 02 Sperati Prevention And Management Of Acute Renal Failure

    1. 1. Prevention and Management of Acute Renal Failure C. John Sperati, M.D. Division of Nephrology Johns Hopkins University SOM [email_address]
    2. 2. Acute Renal Failure <ul><li>Sudden loss of renal function over hours to days </li></ul><ul><li>Reflected by rise in creatinine and/or decrease in urine output </li></ul>
    3. 3. Epidemiology of ARF <ul><li>7.2% of hospitalized patients </li></ul><ul><li>15.7 % CKD vs. 5.3 % nl renal function </li></ul><ul><li>Major Causes: </li></ul><ul><ul><li>Prerenal – Volume depletion, CHF </li></ul></ul><ul><ul><li>ATN – ischemia or nephrotoxin or sepsis </li></ul></ul><ul><li>Other causes: </li></ul><ul><ul><li>AIN – Drug exposure +/- Characteristic UA </li></ul></ul><ul><ul><li>Obstruction – Ultrasound </li></ul></ul><ul><ul><li>Glomerulonephritis – Hematuria, RBC casts, proteinuria </li></ul></ul>Nash K et al. Am J Kidney Dis. 2002 May;39(5):930-6
    4. 4. ARF Requiring Renal Replacement Therapy in Critically Ill Patients Metnitz PGH, et al. Crit Care Med 2002; 30:2051-2058 ** * * *p < 0.001; ** p < 0.05
    5. 5. ICU Mortality with ARF by Era Ympa et al, AJM August 2005
    6. 6. Prevention <ul><li>Identify that a problem even exists </li></ul><ul><ul><li>Cr is an insensitive and often poor marker of renal function in ICU patients </li></ul></ul><ul><li>GFR estimation requires global assessment </li></ul><ul><ul><li>GFR / CrCl equations (inaccurate!) </li></ul></ul><ul><ul><li>Urine output </li></ul></ul><ul><ul><li>I/O and daily weights </li></ul></ul><ul><ul><li>Alternative markers (e.g. phosphorus) </li></ul></ul><ul><ul><li>Drug clearance (e.g. vancomycin) </li></ul></ul>
    7. 7. Approach to Acute Renal Failure— Classification New Rise in Serum Creatinine Prerenal Dehydration CHF Vasoconstriction Intrarenal Glomerular Disease Glomerulonephritis Nephrotic Syndromes Interstitial Nephritis Drug-related Other – infection, idiopathic Acute Tubular Necrosis Ischemia – Hypovolemia, Hypotension Medication – Aminoglycoside, AmphoB, Contrast Post-renal Obstructive Uropathy Vascular
    8. 8. Question <ul><li>When titrating pressors in the patient with septic shock, what MAP might you target? </li></ul><ul><li>A. MAP > 50 mmHg </li></ul><ul><li>B. MAP > 55 mmHg </li></ul><ul><li>C. MAP > 60 mmHg </li></ul><ul><li>D. MAP > 70 mmHg </li></ul>
    9. 9. Renal Autoregulation with Progressive Hypertensive Kidney Disease Palmer NEJM 2002;347 Renal Dysfunction Complicating the Treatment of Hypertension
    10. 10. Glomerular Hypoperfusion <ul><li> ECF volume </li></ul><ul><li> Effective volume (CHF, sepsis, cirrhosis) </li></ul><ul><li>Glomerular Hemodynamic ∆’s </li></ul><ul><ul><li>Vasoconstriction (pre glomerular) </li></ul></ul><ul><ul><ul><li>NSAID/ COX-2 inhibitor </li></ul></ul></ul><ul><ul><ul><li>Contrast </li></ul></ul></ul><ul><ul><ul><li>Amphotericin B </li></ul></ul></ul><ul><ul><ul><li>Cyclosporine/ tacrolimus </li></ul></ul></ul><ul><ul><ul><li>Hypercalcemia </li></ul></ul></ul><ul><ul><li>Efferent vasodilatation </li></ul></ul><ul><ul><ul><li>ACE inhibitors/ ARBs </li></ul></ul></ul>Contrast CSA Ampho ACE-I ARB NSAID
    11. 11. Case 1: 45 year old with Pseudomonal Pneumonia following Cholecystectomy <ul><li>Treated with cefipime and gentamicin for 14 days. Normal BP without orthostasis. Urine output 1 L/day. Baseline creatinine 0.7. </li></ul><ul><li>Labs (POD 16) </li></ul><ul><ul><li>Na + 134, K + 4.9, CL - 108, HCO 3 - 20, BUN 48, Cr 3.0, FeNa=2.4 </li></ul></ul><ul><ul><li>Urinalysis shows granular casts, no white blood cells, no red blood cells </li></ul></ul>POD
    12. 12. <ul><li>Question: The most likely diagnosis is: </li></ul><ul><li>A. Acute tubular necrosis </li></ul><ul><li>B. Hypovolemia </li></ul><ul><li>C. Interstitial nephritis </li></ul><ul><li>D. Post infectious GN </li></ul>Case 1: 45 year old with Pseudomonal Pneumonia and ARF
    13. 13. Acute Tubular Necrosis <ul><li>Ischemic: Prerenal  ATN </li></ul><ul><li>Nephrotoxic: </li></ul><ul><ul><li>Aminoglycosides </li></ul></ul><ul><ul><li>Rhabdomyolysis: cocaine, statins, trauma </li></ul></ul><ul><ul><li>Contrast </li></ul></ul><ul><ul><li>Ampho B, cisplatin, IVIG </li></ul></ul><ul><li>U/A: granular casts </li></ul><ul><li>Treatment: Supportive </li></ul><ul><li>Better outcome in non-oliguria </li></ul>
    14. 14. ATN: Aminoglycoside <ul><li>Duration of Rx - Usually after 5-10 days </li></ul><ul><li>Usually non-oliguric </li></ul><ul><li>May see electrolyte abnormalities </li></ul><ul><ul><li>Mg ++ , K + , others </li></ul></ul><ul><li>Urine may show granular casts </li></ul><ul><li>Predisposed by hypotension, concurrent nephrotoxins and liver disease </li></ul><ul><li>Supportive care as with most ATN </li></ul><ul><li>Recovery usually within 3 weeks </li></ul>
    15. 15. Prerenal vs. ATN <ul><li>TEST Prerenal ATN </li></ul><ul><li>Urinalysis benign granular casts </li></ul><ul><li>BUN/Cr > 20 < 15 </li></ul><ul><li>Urine Na < 20 > 40 </li></ul><ul><li>Urine Osm > 500 ~ 300 </li></ul><ul><li>FENa (%) < 1 > 2 </li></ul><ul><li>( Urine Na x Serum Cr ) x 100 </li></ul><ul><li>( Serum Na x Urine Cr ) </li></ul>
    16. 16. Fractional Excretion of Na + (FENa) <ul><li>(Urine Na x Serum Cr) X 100 < 1% = prerenal </li></ul><ul><li>(Serum Na x Urine Cr) > 2% = ATN </li></ul><ul><li>Normal renal function <1% </li></ul><ul><li>Most accurate with oliguric ARF </li></ul><ul><li>Caveat: </li></ul><ul><ul><li>Possibly < 1% without volume depletion </li></ul></ul><ul><ul><ul><li>Cirrhosis, severe CHF </li></ul></ul></ul><ul><ul><ul><li>Contrast nephropathy, Acute GN </li></ul></ul></ul><ul><ul><ul><li>Rhabdomyolysis </li></ul></ul></ul><ul><ul><li>Possibly > 2% with prerenal state: </li></ul></ul><ul><ul><ul><li>diuretics , severe CRF </li></ul></ul></ul>Steiner AJM 1984:77:699-702
    17. 17. Fractional Excretion of Urea (FEurea) <ul><li>(Urine UN x Serum Cr) X 100 < 35% = prerenal </li></ul><ul><li>(Serum UN x Urine Cr) > 50% = ATN </li></ul><ul><li>May be better than FENa in pts on diuretics (Carvounis et al, Kid Int 2002; 62:2223) </li></ul><ul><li>Rationale: Urea reabsorbed in proximal tubule + inner medulla, not affected by loop and thiazide diuretics </li></ul><ul><li>Caveats: Pre-renal with FEurea > 35% if problem with proximal tubule reabsorption: mannitol, hyperglycemia, acetazolamide, sickle cell </li></ul>
    18. 18. CASE 2: 50 yo man perineal prostatectomy x 6 hrs with nl BP. Nl labs pre op. POD 1: I/O 3L / 0.5L <ul><li> urine output despite IVF and foley: PE: BP 132/85, euvolemic </li></ul><ul><li>143 108 20 Ca 2+ = 7.0 4 hrs 146 106 23 </li></ul><ul><li>5.8 19 2.2 Phos = 6.0 6.4 14 2.6 </li></ul><ul><li>U/A: dip - lg blood, micro – no rbcs. Muddy casts </li></ul><ul><li>Question: What is the next step in your evaluation? </li></ul><ul><ul><li>A. Obtain renal ultrasound </li></ul></ul><ul><ul><li>B. Measure urine myoglobin </li></ul></ul><ul><ul><li>C. Check FeNa </li></ul></ul><ul><ul><li>D. Check serum CPK </li></ul></ul><ul><ul><li>E. Blood smear for hemolysis </li></ul></ul>
    19. 19. ARF after Surgical Procedure <ul><ul><li>Rhabdomyolysis – body positioning </li></ul></ul><ul><ul><li>Hypotension and medication induced ATN are most common </li></ul></ul><ul><ul><li>Urinary tract obstruction - narcotics </li></ul></ul>Positioning for perineal prostatectomy
    20. 20. ATN: Rhabdomyolysis/ Myoglobinuria <ul><li>Several important etiologies: </li></ul><ul><ul><li>Drugs – Alcohol, cocaine & heroin </li></ul></ul><ul><ul><li>Trauma/Compression/Hyperthermia </li></ul></ul><ul><ul><li>Medications – statins </li></ul></ul><ul><li>Clues </li></ul><ul><ul><li>Exposures above </li></ul></ul><ul><ul><li>Urinary heme without hematuria </li></ul></ul><ul><ul><li>Pigmented granular casts in urine </li></ul></ul><ul><li>Diagnosis </li></ul><ul><ul><li>Serum CPK </li></ul></ul>Derek Fine, Unpublished Data 376 Hospitalized pts with CPK > 10,000
    21. 21. Rate of Decline of CK is Similar Regardless of Creatinine
    22. 22. ATN: Rhabdomyolysis <ul><li>Dangerous complications </li></ul><ul><ul><li>Hyperkalemia </li></ul></ul><ul><ul><li>Compartment syndrome </li></ul></ul><ul><ul><li>Hypocalcemia (hypercalcemia with recovery) </li></ul></ul><ul><li>Treatment </li></ul><ul><ul><li>Early aggressive hydration with isotonic saline </li></ul></ul><ul><ul><ul><li>May need > 10 l IVF to achieve euvolemia </li></ul></ul></ul><ul><ul><ul><ul><li>Trauma victims in Lebanon </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Ron, Arch Int Med 1984 </li></ul></ul></ul></ul><ul><ul><li>Urine alkalinization – pH > 6.5 </li></ul></ul><ul><ul><li>Forced diuresis (mannitol if urine output adequate) – keep UO 100 - 300 ml/hr </li></ul></ul>146 106 23 6.4 14 2.6
    23. 23. Hyperkalemia Treatment <ul><li>Calcium gluconate 1Amp </li></ul><ul><li>Insulin 10 units reg IV + 1 Amp D50 </li></ul><ul><ul><li>Onset 15’, peak 1 hr </li></ul></ul><ul><ul><li> K + ~ 0.5-1.5 mEq/L in 1 hr </li></ul></ul><ul><li>Albuterol neb 10-20mg (4-8 x nl dose) </li></ul><ul><ul><li>Use with insulin (40% failure alone) </li></ul></ul><ul><ul><li>Onset rapid, peak 90’ </li></ul></ul><ul><ul><li> K + ~ 0.5-1 mEq/L in 1 hr </li></ul></ul><ul><li>Bicarbonate if pH < 7.2 </li></ul><ul><li>Kayexylate 30-60 gm in 70% sorbitol </li></ul><ul><ul><li>Onset 1-2 hrs, peak 2-4 hrs </li></ul></ul><ul><ul><li>60 gms  K + ~ 0.8-1.0 mEq/L/24 hrs </li></ul></ul><ul><ul><li>Contraindicated with ileus </li></ul></ul>Blumberg, AJM 1988 Oct, 85(4): 507 HyperK in dialysis patients
    24. 24. <ul><li>Fever, cough, infiltrate  Pseudomonas </li></ul><ul><li>Tobra, Piperacillin x 2 wks, NSAIDs; CXR improved </li></ul><ul><li>BUN/Cr 14/0.6  32/3.2 </li></ul><ul><li>PE now: T=38.3, RR nl, truncal rash </li></ul><ul><li>U/A: tr prot, 2+ heme, many rbc’s, wbc’s </li></ul>Case 3: 28 year old gunshot victim <ul><li>Question: What is the best diagnostic study? </li></ul><ul><ul><li>A. Wright stain of urine </li></ul></ul><ul><ul><li>B. Tobramycin level </li></ul></ul><ul><ul><li>C. 24 hr urine calcium, oxalate </li></ul></ul><ul><ul><li>D. Kidney biopsy </li></ul></ul><ul><ul><li>E. Peripheral eosinophil count </li></ul></ul>
    25. 25. Acute Interstitial Nephritis: Signs (Rossert. Kid Int 60 2001 pp804-17) Methicillin Others
    26. 26. Drug Induced AIN <ul><li>AIN onset </li></ul><ul><ul><li>3 – 5 days on second exposure </li></ul></ul><ul><ul><li>Up to several weeks on first exposure </li></ul></ul><ul><li>Absence of signs does not R/O AIN </li></ul><ul><li>Rx: Discontinue medication, ? p.o. steroids </li></ul>
    27. 27. CASE 4: 48 y.o. with CAD develops acute renal failure post cardiac catheterization <ul><li>Cr increase noted on day 4 post procedure (baseline: 1.1 ; day 4: 1.5) </li></ul><ul><li>Medications: lisinopril, metoprolol, atorvastatin, aspirin </li></ul><ul><li>Exam nl, labs show Cr continues to increase (now 5.0) 8 days after the procedure </li></ul>Question: This patient likely has which of the following? A. Interstitial nephritis B. Contrast induced renal failure C. Atheroembolic disease D. Pre-renal renal failure
    28. 28. ARF after Arterial Catheterization <ul><li>Post Contrast </li></ul><ul><ul><li>ARF within 24-48 hours </li></ul></ul><ul><ul><li>Prevention with hydration pre and post procedure </li></ul></ul><ul><ul><li>Recent evidence of benefit of sodium bicarbonate infusion and possibly N-acetyl cysteine </li></ul></ul>Merten et al, JAMA, May 19, 2004 154 mEq/l NaHCO 3 bolus 3 ml/kg/hr 1 hr before; 1 ml/kg/hr infusion for 6 hours after
    29. 29. ARF after Arterial Catheterization <ul><li>If not recovering by day 5 post contrast must consider atheroembolic disease </li></ul><ul><ul><li>Can occur spontaneously or after other vascular trauma </li></ul></ul><ul><ul><li>Hollenhorst plaque, livedo reticularis and peripheral emboli </li></ul></ul><ul><ul><li>Eosinophiluria/eosinophilia, low complement, high amylase </li></ul></ul><ul><ul><li>Important to stop anticoagulation – otherwise supportive care </li></ul></ul>
    30. 30. Classical Approach to ARF Management <ul><li>Conservative/Supportive </li></ul><ul><ul><li>Prevent further ischemic toxic injury </li></ul></ul><ul><li>Dialysis when indicated </li></ul><ul><ul><li>Azotemia </li></ul></ul><ul><ul><li>Volume overload </li></ul></ul><ul><ul><li>Acidosis </li></ul></ul><ul><ul><li>Hyperkalemia </li></ul></ul><ul><ul><li>Drug intoxications </li></ul></ul>
    31. 31. Controversial Issues (or not) <ul><li>There is little evidence that low-dose dopamine is of benefit in prevention or treatment of ARF </li></ul><ul><li>Loop diuretics do not improve outcome in ARF. May contribute to increased mortality if delays RRT </li></ul><ul><li>Timing of RRT initiation </li></ul><ul><ul><li>Early (BUN < 60 – 100) vs late (BUN > 100) </li></ul></ul>
    32. 32. Renal Replacement Therapies <ul><li>Intermittent hemodialysis (IHD) </li></ul><ul><li>Continuous veno-venous hemofiltration (CVVH) </li></ul><ul><li>CVV hemodialysis (CVVHD) </li></ul><ul><li>CVV hemodiafiltration (CVVHDF) </li></ul><ul><li>Slow low efficiency dialysis (SLED) </li></ul><ul><li>Peritoneal dialysis (PD) </li></ul><ul><li>Slow continuous ultrafiltration (SCUF) </li></ul>
    33. 33. Prescribed Dialysis in ARF Evanson JA et al. Kidney Int. 1999 Apr
    34. 34. CVVH Dose Trial Ronco C et al. Lancet. 2000 Jul 72 58 32 UF (L/24h) 22 24 22 Apache II 11 12 14 % Sepsis 63 59 61 Age 140 139 146 Number Group 3 45 ml/kg/h Group 2 35 ml/kg/h Group 1 20 ml/kg/h
    35. 35. CVVH Dose Trial – High vs Low Dose Ronco et al: Lancet 2000; 356:26-30
    36. 36. Renal Replacement Therapy in ARF: Dose of CVVH Ronco et al: Lancet 2000; 356:26-30
    37. 37. Daily Dialysis in ARF Schiffl H et al. N Engl J Med. 2002 <ul><li>172 eligible patients </li></ul><ul><li>160 randomized </li></ul><ul><ul><li>Daily dialysis vs every other day dialysis </li></ul></ul><ul><ul><li>74 pts daily vs 72 patients every other </li></ul></ul>0.94 +/- 0.11 0.92 +/- 0.16 Delivered Kt/V 1.21 +/- 0.09 1.19 +/- 0.11 Prescribed Kt/V 243 +/- 25 248 +/- 45 QB 3.4 +/- 0.5 3.3 +/- 0.4 Time Alternate Day Daily
    38. 38. Frequency of Hemodialysis in ARF Schiffl H et al. N Engl J Med. 2002
    39. 39. Frequency of Hemodialysis in ARF Comparison of Groups During Therapy Schiffl H, et al. N Engl J Med 2002; 346:305-310
    40. 40. Equivalent Urea Clearance Adapted from Casino FG et al. Nephrol Dial Transplant. 1996 Aug.
    41. 41. Dialysis Modality in ARF <ul><li>RR of death for IHD versus continuous </li></ul>Tonelli AJKD 2002 40:875-885.
    42. 42. Dialysis Modality in ARF <ul><li>Continuous vs intermittent </li></ul><ul><ul><li>Absence of adequately powered studies </li></ul></ul><ul><ul><li>Best modality for the unselected ICU patient is unclear </li></ul></ul><ul><ul><li>Consensus: Continuous therapy for patients with unstable hemodynamics, increased ICP </li></ul></ul>
    43. 43. Final Thoughts <ul><li>Better to prevent than to treat ARF </li></ul><ul><li>Kidney biopsies are not contraindicated in ICU setting </li></ul><ul><li>Is more dialysis better? Ongoing trials underway </li></ul><ul><li>Best modality of RRT and optimal timing of initiation are unknown </li></ul>