Dialysis adequacy in patients with acute renal failure

Measurement of dialysis adequacy in patients with end-stage renal disease involves the use of urea kinetic modeling, which is a reflection of both dietary protein intake and efficiency of small solute clearance. Different dialytic modalities are available for patients in acute renal failure, including intermittent hemodialysis, continuous renal replacement therapies and peritoneal dialysis. In recent years, there has been a growing effort to measure dialysis adequacy in patients with acute renal failure using urea kinetic modeling. This initiative has been driven by the persistently high mortality rates in patients with dialysis-requiring acute renal failure, which may partly be related to inadequate dialysis dosing. In the setting of acute renal failure, dialysis adequacy has been measured using both single-pool and double-pool urea kinetics, as well as blood-based and dialysate-based urea kinetic modeling. Unfortunately, current goals and methods of measuring dialysis adequacy have been extrapolated from the end-stage renal disease patient population. These extrapolations are problematic because of differences in total body water, protein catabolic rate, and vascular access. Continuous renal replacement therapy has theoretical advantages over intermittent hemodialysis, including a decreased tendency to induce hypotension, and improved solute clearance and fluid removal, while allowing intensive nutritional support, and a better clearance of medium- to large-size molecules. The latter may play a significant role in patients with sepsis-associated acute renal failure. To date, comparative studies are scant and equivocal in establishing the superiority of a particular dialysis dose or modality.