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December 20, 2012

Continuous dialysis for ICU patients provides better fluid removal

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In a review article published in the Clinical Therapeutics section of the Dec. 27, 2012, issue of the New England Journal of Medicine, a University of Alabama at Birmingham  nephrologist and internationally known expert on continuous renal-replacement therapy explains why performing dialysis on intensive care unit  patients with kidney failure, slowly over a 24-hour period as compared to standard dialysis techniques, provides better hemodynamic stability and fluid removal.

“It’s a therapy with which many physicians are not familiar, which is why the New England Journal invited me to write the article,” said Ashita Tolwani, M.D., professor of medicine in the Division of Nephrology.

Tolwani said patients in the ICU often develop kidney failure from multiple causes, including severe infection, low blood pressure and medications. The mortality rate for critically ill patients with acute kidney failure is greater than 60 percent. Because these patients are so unstable, they do not tolerate regular dialysis procedures well, which can lead to cardiac arrest.

“CRRT is far gentler than regular dialysis,” Tolwani said. “It runs 24 hours a day, continuously removing fluids, solutes and toxins the kidneys build up. It is the preferred type of dialysis treatment for these critically ill patients, because it allows physicians to give patients whatever fluids, nutrition, antibiotics or other medications they need without worrying about the accumulation of waste products and fluid from the failing kidneys.”

UAB Hospital logs more than 5,000 patient-days per year with the therapy. Because CRRT is a complicated therapy, more so than regular dialysis, it is only available at hospitals that have the expertise to provide it. It requires specialized physician knowledge and special training for nurses. To make the therapy run 24 hours, it requires special anticoagulants. Tolwani has patented one such anticoagulant used in CRRT.

“We have one of the largest CRRT programs in the U.S.,” Tolwani said. “We have 25 CRRT devices and run 10-15 devices a day. Most other places have fewer than 10 CRRT devices.”

Tolwani hopes that by increasing knowledge of the procedure in the medical community, more patients will be treated effectively.

“The review article is for clinicians to understand more about the therapy, its indications and advantages, the evidence for it, its side effects, the process by which it’s done and the physiology behind it,” she said.

To this end, the UAB Division of Nephrology and UAB Hospital Nursing each year host a two-day training symposium on CRRT for clinicians, nurses and pharmacists. The next session will be held in September 2013. It will incorporate one day of didactics and one day of simulation training using UAB’s simulation center.

“In-depth practical training for CRRT is not widely available, so we provide the annual symposium for those who do not have access to such training at their institutions,” Tolwani said.