THE TREATMENT OF AKI IN NEPHROLOGY HOSPITALIZATION: THE SLE-HDF 15 LITRES IN 10 HOURS

Abstract

The AKI in intensive care has been widely treated by international and national guidelines. The treatment of AKI in patients not requiring admission in Intensive Care Unit, but often hospitalized in Nephrology Unit, it is showed of less relevance. For over 5 years we have used for the treatment of AKI of patients admitted in Nephrology Unit an intermittent slow technique, implemented in approximately 600 patients with AKI for a total of about 3000 treatments. In this study we report the clinical results obtained in 100 consecutive patients referred to our Nephrology Unit from 1st January 2014. We excluded the patients with AKI and lactic acidosis by metformin, which were treated with CVVHDF. The Dialysis Protocol provides a slow low efficiency intermittent treatment called SLE-HDF (Sustained Low Efficiency Hemo-Dia-Filtration), with 10-hour duration, 1.5 L/h dialysate for a patient up to 75 kg, 2 L/h up to 85 kg, 2.5 L/h over 85 kg. Half of the dialysate was used in convention in post and half in diffusion. Endpoints were the recovery of renal function and the survival of the patient. On each patient was calculated on at least one seat, the Kt/V urea (UKt/V).
Were studied 100 patients, 45 females and 55 males, with mean age 79.4 + 11 years. The weight was 74 kg + 18 kg at the start of treatment. The 65% of patients had diuresis < to 500 ml/24 hours. The causes of AKI were: 41% heart failure, 31 % AKI on MRC, 7% rhabdomyolysis, 6% Hepato-renal Syndrome, 4% sepsis, 11 % other causes. Major comorbidities were heart disease (63%), diabetes (50%), COPD (38%), age over 85 years, cancers 23, liver disease 16, hypotension requiring amine 15, sepsis 10. In total in the 100 patients, 512 treatments were performed, average 5.12 + 3.7. The mean UKt/V was 0.4 + 0.05 per session. The deaths were 43. Patients discharged were 57. Of these, 43 had a recovery of renal function. Fourteen patients have not recovered renal function and were admitted for chronic dialysis treatment. In conclusion, our protocol of SLE-HDF, which uses volumes of dialysate sharply lower than used in literature, has been shown to be effective in correcting the biochemical profile of the patient with AKI. The clinical results are considered satisfactory, having obtained the improvement in 57% of patients, considering that the 43 deaths, 10 were suffering from Hepato-cirrhosis and 13 from malignant neoplasm. Further studies are needed to confirm our findings. KEYWORDS: AKI, SLE-HDF, RRT

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Introduzione

Nell’ultimo decennio l’argomento AKI in terapia intensiva ha visto un proliferare di letteratura ed è stato ampiamente trattato da linee guida internazionali (1) e nazionali (2). Minor interesse ha mostrato nel tempo il trattamento dell’AKI in pazienti non richiedenti ricovero in terapia intensiva, in genere ospedalizzati in degenza nefrologica. Spesso si tratta di pazienti critici con molte comorbidità, frequentemente con instabilità emodinamica. E’ ipotizzabile che anche i pazienti con AKI in degenza nefrologica possano trarre beneficio da trattamenti lenti a bassa efficienza, siano essi continui o quotidiani intermittenti. Per questa categoria di pazienti le linee guida (2) rilevano come sia estremamente complesso stabilire la dose dialitica da prescrivere, anche perché spesso la dose prescritta è inferiore a quella ottenuta (3, 4, 5). Non sembra definito, in caso di tecniche ibride, lente intermittenti, quale indice di efficienza dialitica sia da applicare. Nel nostro centro da più di 5 anni viene attuato un nuovo protocollo dialitico per il trattamento dell’AKI che, finalizzato ad ottenere un Kt/V dell’urea almeno uguale a quello della dialisi giornaliera per i pazienti con MRC, fosse di facile attuazione e di basso impatto per il personale infermieristico. Con tale protocollo sono stati trattati circa 600 pazienti. In questo studio abbiamo valutato i risultati clinici in 100 pazienti con AKI avviati consecutivamente al trattamento dialitico nella nostra Unità Operativa dal 1° gennaio 2014.
 

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