Renal replacement therapy in special situations: heart failure and neurological injury

The cardiorenal syndrome is a complicated and increasingly prevalent entity requiring a multidisciplinary approach. Renal replacement therapy (RRT) in the form of slow ultrafiltration (UF) demonstrates promise for the treatment of acutely decompensated heart failure. Despite the lack of evidence for decreased mortality, there is considerable short-term benefit in decreased rehospitalizations and a restoration of diuretic responsiveness. Given the potential for improvement in quality of life and cost if hospitalizations are minimized, slow UF should be considered in patients with repeated hospitalization for decompensated heart failure. Acute neurologic injury is a highly unstable state requiring strict adherence to evidence-based guidelines to achieve the best possible functional outcomes. With improved short-term survival, a greater burden of non-neurologic injury may hinder long-term functional recovery. Acute kidney injury is among such important considerations that can lead to worsened neurological injury. Careful application of continuous modalities of therapy, probably early in the course of illness to avoid intradialytic osmolar shifts and provide hemodynamic stability, will allow for unimpeded neurologic recovery. Newer evidence on dose and RRT modality on patients with acute and chronic brain injury will certainly add important knowledge to this field.