Renal replacement therapy

According to Perhimpunan Nefrologi Indonesia (PERNEFRI) (2003, ideally all patient with GFR less than 15 mL/minute, GFR less than 10 mL/minute with uremic symptom or malnutrition, and GFR less than 5 mL/minute despite presence of symptom should be indicated for dialysis. Specific indication are given to patients with acute complication, such as pulmonary oedema, hyperkalemia, recurrent metabolic acidosis, and diabetic nephropathy.

Indications for Initiation of Dialysis Although there has been an increased appreciation for the need for early and aggressive management of ARF in the ICU, there are no standards for initiation of dialysis, and many nephrologists avoid dialysis initiation for as long as possible. Two major factors contribute to the tendency to delay dialysis. One factor is that the dialysis procedure itself has associated risks. Hypotension, arrhythmias, and complications of vascular access placement are common. A second factor is concern that dialysis may delay recovery of renal function. This contention is supported by animal data in which hypotension resulted in recurrent renal ischemia and by human studies that showed a decline in the glomerular filtration rate (GFR) during and after the intermittent hemodialysis session. Several factors need to be considered when making the decision to provide renal replacement therapy. It is important to recognize that for patients in the ICU, ARF usually does not occur in isolation from other organ-system dysfunction. Consequently, providing dialysis can be viewed as a form of renal support for multiorgan dysfunction rather than renal replacement. In the presence of oliguric renal failure, administration of large volumes of fluid to patients with MOF may lead to impaired oxygenation. In such a setting, early intervention with extracorporeal therapies for management of fluid balance significantly may impact the function of other organs, even in the absence of traditional indices of renal failure such as marked azotemia. In general, indications for dialysis fall into one of three broad categories: (1) solute indications such as marked azotemia, (2) volume indications such as in fluid overload, or (3) both.

The indication for initiation influences outcome. Patients dialyzed for solute control had a better outcome than those dialyzed for volume control. Patients dialyzed for solute and volume control had the worst outcome. It seems that volume overload tends to confer a poorer prognosis. This notion is supported by a number of observational studies. Studies have suggested that achieving a negative fluid balance in the first 3 days of admission for septic shock is a predictor of better survival. Consequently, fluid regulation should be an important consideration when deciding to initiate dialysis in ICU patients with ARF. Such renal support provides volume space that permits for the administration of adequate nutritional support without limitation. In addition to volume overload, solute disturbances such as hyperkalemia may predispose to life-threatening arrhythmias, and uncontrolled uremia may lead to a variety of serious complications. Maintaining electrolyte, acid-base, and solute homeostasis is another important factor when considering initiation of dialysis. (abdeen, ravindra< Mehta 2002)