Respecto a la jurisprudencia nacional

Insuffi cient metabolic clearance correlates with inadequate treatment and should be avoided. However, it is not clear what the lowest acceptable dose of acute RRT is.

In the chronic setting, ESRD patients receiving thrice-weekly intermittent haemodi-alysis with URR <60 % had a higher mortality compared to patients with URR of 65–69 % (odds ratio for mortality 1.28 for URR of 55–59 % and 1.39 for URR

<55 %) [ 29 ]. Thrice-weekly IHD with an estimated URR <60 % provides azotemic control similar to that of approximately 10–15 mL/kg/h of CRRT. Since it is unlikely that critically ill patients have a lower requirement for RRT in comparison with stable haemodialysis patients, it has been suggested that CRRT doses of <15 ml/

kg/h are too low in critically ill patients, especially in the acute phases of illness.

High dose CRRT is associated with higher clearance of urea and creatinine but also increased losses of other substances. Some losses may be obvious (ie phos-phate) but others may be hidden and not immediately recognized, for instance trace elements and micronutrients [ 25 ]. There is also increasing recognition that high dose CRRT increases drug clearance and may potentially lead to sub-therapeutic

drug levels, including antibiotics, resulting in treatment failure [ 5 , 30 , 31 ].

The IVOIRE study clearly demonstrated reduced average elimination half-life of administered antibiotics when using high doses of 70 ml/kg/h [ 25 ].

Awareness about the potential dangers of increased clearance is necessary and close drug monitoring is essential when using RRT above the current recommended doses.

References

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Key Messages

1. CRRT dose is expressed as the amount of dialysis/hemofi ltration fl ow delivered to the patient in ml/kg per hour.

2. Current international guidelines recommend delivering an effl uent volume of 20–25 ml/kg per hour for post-dilution CRRT in AKI, taking into account the degree of ‘pre-dilution’ and ‘fi lter-down’ time.

3. CRRT doses of <15 ml/kg per hour are believed to be too low in critically ill patient, especially in the acute phases of illness.

4. Increasing evidence suggests that fl uid overload is detrimental to both renal outcome and survival in critically ill patients with AKI. It is not possible to recommend a general net ultrafi ltration rate, instead the ultrafi ltration rate should be tailored to the patients’ needs and hemody-namic and fl uid status.

5. The application of high-volume hemofi ltration in severe sepsis and septic shock is not recommended based on the results of human studies.

6. Drug clearance, including antibiotics, is affected by (high dose) CRRT and may potentially lead to sub-therapeutic drug levels resulting in treatment failure.

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H.M. Oudemans-van Straaten et al. (eds.), Acute Nephrology for the Critical Care Physician, DOI 10.1007/978-3-319-17389-4_14