Dialysis and related therapies

Dialysis continues to be the major supportive intervention in severe acute renal failure (ARF). The impact of dialysis on outcomes from ARF is best viewed from an historical perspective when comparisons can be made with the predialysis era. The overall effect of dialysis therapy on survival has been limited primarily to reducing death from direct renal-related causes such as hyperkalemia and pulmonary edema. Attempts to improve survival in ARF patients requiring dialysis has been focused in areas in intensity of therapy, dialysis modalities, and ultrafiltration membranes. Optimal choices in these areas continue to be controversial with additional controlled studies required. Because of the continuing high mortality in ARF regardless of specific dialysis practices, a number of recent studies have examined the value of outcome predictors in choosing patients for dialysis. This is another complex arena in which there are still insufficient data to predict in all settings the exact probabilities of survival. Pediatric dialysis for ARF infrequently receives discussion in primarily adult-oriented critical care. There has been an increasing refinement in dialysis indications, access, and modalities in recent years including the use of continuous dialysis in infants and children.