The role of continuous renal replacement therapy in the future treatment of acute renal failure

In considering continuous renal replacement therapy (CRRT) in future therapeutic regimens for acute renal failure (ARF), three relevant areas of interest have been examined: changes in the nature and perception of ARF as an illness; the emerging roles of CRRT in ARF management; and the use of dialysis modes in conjunction with newer pharmacologic treatments in ARF, Regarding changing patterns and perceptions of ARF, there are a number of important issues in relation to future therapy, ARF in the 1990s is predominantly a nonoliguric disorder that has a better outcome than oliguric ARF and may have a positive effect on overall mortality compared with previous decades, Rates of increases of serum creatinine (Scr) and blood urea nitrogen (BUN) levels in the current decade are little changed, however, in large part because of catabolism and high protein infusion formulae, Of related interest is recent information that baseline serum creatinine is a poor predictor of subsequent dialysis need and mortality in ARF. Other outcome predictive scoring systems, while improved, still lack the precision for general application in patient treatment decisions, Given that there is increasing evidence of abnormal vascular reactivity predisposing to recurrent ischemia in ARF and new evidence of negative renal effects of bioincompatible dialyzer membranes, the issue of early and intensive dialysis in ARF needs to be re-examined using CRRT with biocompatible membranes, rather than standard intermittent dialysis, Finally, pharmacologic agents currently under study that may have clinical efficacy have variable levels of hypotensive side effects, It is very likely that when combination treatment using dialysis and these newer drugs is considered, it will require CRRT. (C) 1996 by the National Kidney Foundation, Inc.