EDTNA/ERCA European Dialysis and Transplant Nurses Association/
European Renal Care Association
EDTNA/ERCA Project Website Dresden 2015
Patient-centred Renal Care – A Multidisciplinary Approach to Holistic Health
Journal of Renal Care

ARF Monography

Acute Renal Failure in Childhood
Anticoagulation Therapy in Acute Renal Failure Extracorporeal Treated Patients
Cardiovascular Outcome in Critically Ill Patients Treated with Continuous Haemodiafiltration – Beneficial Effects of Bicabonate-Buffered Replacement Fluids
Continuous Renal Replacement Therapy
Early Management and Prevention of Acute Renal Failure (ARF)
Editorial
EDTNA/ERCA Dialysis Technology Journal Club 2001/2 Summary
Effects of Different Doses in Continuous Veno-Venous Haemofiltration on Outcomes of Acute Renal Failure: a Prospective Randomised Trial
Ethical Aspects of Withdrawing/Withholding Renal Replacement Therapies on Patients in Acute Renal Failure in an Intensive Care Unit
Importance of Increased Ultrafiltration Volume and Impact on Mortality: Sepsis and Cytokine Story and the Role of CVVH
Nursing Care Plans for Renal Patients Following the Krohwinkel Model
Nutritional aspects of Acute Renal Failure
The effects of Acute Renal Failure on the family
Vascular Access in Acute Renal Failure
Who Should Manage Continuous Renal Replacement in the Intensive Care Setting? A Nursing Viewpoint.

 

Acute Renal Failure in Childhood

Willem Proesmans, Renal Unit, Department of Paediatrics, Leuven, Belgium

Address for correspondence
Willem Proesmans
Renal Unit
University Hospital Gasthuisberg
Herestraat 49
3000 Leuven
Belgium
Phone 32/16/34 38 41
fax 32/16/34 38 42
E-mail: willem.proesmans@uz.kuleuven.ac.be

Key Words
Paediatrics
Acute Renal Failure
Treatments

Biodata
Willem Proesmans qualified as a Doctor at the University of Leuven in July 1964. From 1964-1967, he specialised in Paediatrics and from 1967-1969 Paediatric Nephrology. Since 1969, he has been Head of the Renal Unit at the Department of Paediatrics at the University Hospital Gasthuisberg Leuven and since 1999, he has been Editor of the European Journal of Paediatrics.

Summary
The definition of acute renal failure is a sudden reduction in renal function of at least 50 percent and is characterized by rising serum levels of waste products such as urea and creatinine, by disturbed water and electrolyte metabolism and changes in the amount or composition of the urine. The clinical manifestations are extremely variable, there are very many causes and the outcome depends mainly on the underlying condition, which is either in the kidneys or in the body as a whole. This paper will discuss the pathophysiology of acute renal failure and the etiology including prerenal, renal and postrenal causes. Clinical findings, diagnosis and treatment will be discussed and complications of this life-threatening condition highlighted. The final part of the paper deals with the prognosis of acute renal failure.

Suggested Readings

  1. Andreoli SP. Management of acute renal failure. In : Barratt TM, Avner ED, Harmon WE (eds) Pediatric Nephrology 4th ed, Lippincontt, Williams & Wilkins, Baltimore, 1999; pp 1119-1134
  2. Evan ED, Greenbaum LA, Ettenger RB Principles of renal replacement therapy in children. Pediatric Clinics of North America 1995; 42: 1579-1602
  3. Flynn JT. Choice of dialysis modality for management of pediatric acute renal failure. Paediatric Nephrology 2002; 17: 61-69
  4. Hentschel R, Lodige B, Bulla M. Renal insufficiency in the neonatal period. Clinical Nephrology 1996; 46: 54-58
  5. Kelles A, Van Dyck M, Proesmans W. Childhood haemolytic uraemic syndrome: long-term outcome and prognostic features. European Journal of Paediatrics 1994; 153: 38-42
  6. Mendley SR, Langman CB. Acute renal failure in the pediatric patient. Advanced Renal Replacement Therapy 1997; 4 [Suppl 1] : 93-101
  7. Proesmans W. Hämolytisch-urämisches Syndrom In : Pädiatrische Nephrologie, Schärer K, Mehls O (eds) Springer Verlag, Berlin. 2002; pp 235-242
  8. Sadowski RH, Harmon WE, Jabs K. Acute hemodialysis of infants weighing less than five kilograms. Kidney International 1994; 45: 903-906
  9. T?nshoff B. Akute Niereninsuffizienz. In: Pädiatrische Nephrologie, Schärer K, Mehls O (eds) Springer Verlag, Berlin. 2002; pp 359-371
  10. Warady BA, Bunchman T. Dialysis therapy for children with acute renal failure: survey results. Paediatric Nephrology 2000;15: 11-13
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Anticoagulation Therapy in Acute Renal Failure Extracorporeal Treated Patients

J-Y De Vos, haemodialysis Unit, Ronse, Belgium

Address for correspondence
Jean-Yves DE VOS
vzw WERKEN GLORIEUX
Dialysis Unit
Hogerlucht 6
9600 RONSE
BELGIUM
Tel: +32 55 23 37 03
Fax:+32 55 23 37 47
Email: 106111.2261@compuserve.com

Biodata
Jean-Yves De Vos completed graduate general nursing studies in 1979 in Ghent, Belgium. He has worked in the dialysis field for over twenty years and is presently part time head nurse and part time research nurse. He is a member of the EDTNA/ERCA Research Board and has presented various papers at EDTNA/ERCA Conferences since 1981 and at other local, national and international conferences. He is an executive committee member of the Flemish (Belgian) National organisation for renal care workers ( ORPADT ).

Key words
Anticoagulation
Acute renal failure
Extracorporeal

Summary
In extracorporeal techniques, as used for Acute Renal Failure (ARF) treatments, blood is constantly exposed to foreign surfaces. These foreign surfaces include the catheter(s), blood tubings, the dialyser membrane and all artificial materials used for such techniques in general. Blood begins to clot as soon as it strikes a foreign surface. The foreign surface initiates the clotting process. The extracorporeal circuit is prone to clotting during acute treatments unless some form of anticoagulation is employed. On the other hand, this specific group of patients is often at increased risk of bleeding (cfr. Post-operative patients and post-renal-transplant patients, patients with Multiple Organ Failure (MOF) often including liver disturbances). It should be kept in mind that patients with renal failure have a defect in platelet function resulting in altered platelet-vessel wall interaction. Over time, as the extracorporeal treatment progresses, the platelets become more adhesive or sticky. The blood becomes more likely to clot.

Performing effective therapy with low bleeding risk in ARF patients is a challenge requiring knowledge, skills and experience.

Bibliography

  1. Kjellstrand CM, Teehan BP. Anticoagulation-Acute Renal Failure. Replacement of Renal Function by Dialysis. 4th. Revised edition. Kluwer Academic Publishers 1996. pp 842-843.
  2. De Vos JY. A nursing view of future haemodialysis anticoagulation treatments. EDTNA/ERCA Journal XXVI, nr.4, October-December 2000. pp 10-12.
  3. De Vos JY, Marzougui H, Hombrouckx R. Heparinisation in chronic haemodialysis treatment : bolus injection or continuous homogenous infusion ? EDTNA/ERCA Journal XXVI, nr.1, January-March 2000. pp 20-21.
  4. Fisher KG, van de Loo A, Bohler J. Recombinant hirudin ( lepirudin) as anticoagulant in intensive care patients treated with continuous haemodialysis. Kidney International Supplement 1999;72:S46.
  5. Ward DM. The approach to anticoagulation in patients treated with extracorporeal therapy in the intensive care unit. Advanced Renal Replacement Therapy 1997;4:160.
  6. Mehta RL, McDonald BR, Aguillar MM, Ward DM. Regional citrate anticoagulation for continuous arteriovenous haemodialysis in critically ill patients. Kidney International 1990;38:976.
  7. Davenport A, Will EJ, Davison AM. Comparison of the use of standard heparin and prostacyclin anticoagulation in spontaneous and pump-driven extracorporeal circuits in patients with combined acute renal failure. Nephron 1994;66:431.
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Cardiovascular Outcome in Critically Ill Patients Treated with Continuous Haemodiafiltration – Beneficial Effects of Bicabonate-Buffered Replacement Fluids

Michael Barenbrock, MD and Roland M. Schaefer, MD. Department of Medicine D, University of Muenster, Germany

Address for correspondence
Prof. Dr. RM Schaefer
Medizinische Klinik und Poliklinik D
Universitätsklinikum Münster
Albert-Schweitzer-Str.33
D-48149 Muenster/GERMANY

Key words
Acute renal failure
Haemofiltration
Replacement fluids

Biodata
Roland M. Schaefer graduated from Roentgen High School, Wuerzburg in 1973. He graduated as an MD in 1980. He is a member of the German Society of Nephrology, German Society of Internal Medicine, American Society of Nephrology, the Polish Society of Nephrology, the European Dialysis & Transplant Association and the International Society of Nephrology

Introduction
Mortality is high in critically ill patients with acute renal failure despite many technical advances in renal replacement therapy over the past decades (1,2,3). This has been attributed to an increase in severe cases with multiple organ failure (4). One objective of continuous renal replacement therapy is to maintain normal or near-normal acid-base balance in patients with acute renal failure (5). In standard haemofiltration solutions, lactate, which is converted to bicarbonate in the liver, is used as the buffer to correct acidosis (5). In critically ill patients with multiple organ failure, metabolism of lactate might be diminished and hyperlactatemia caused by lactate infusion may have multiple negative effects (5,6,7).

In this context, bicarbonate-buffered replacement fluids have been suggested as an alternative to lactate by a number of authors (8,9,10). However, only recently a head-to-head study comparing the effects of bicarbonate-versus lactate-buffered replacement fluids on cardiovascular outcome in critically ill patients has been conducted (11). This article reviews the design and results of our trial, discusses how this relates to other published work on replacement fluids and ends by addressing the implications for renal replacement therapy in critically ill patients. Taken together, results from the RF-Bic trial confirm that the administration of bicarbonate-buffered replacement fluids during CVVH is by far superior in normalizing acidosis as compared to lactate-containing fluids.

References

  1. Himmelfarb. Dialytic therapy in acute renal failure: No reason for nihilism. Seminars in Dialysis 1996; 9: 230-234
  2. Kierdorf HP, Sieberth HG. Continuous renal replacement therapies versus intermittent hemodialysis in acute renal failure: What do we know? American Journal of Kidney Diseases 1996; 28 (suppl3): S90-S96
  3. Chew SL, Lins RL, Daelemans R, DeBroe ME. Outcome of acute renal failure. Nephrology, Dialysis, Transplantation 1993; 8: 101-107
  4. Cameron JS: Acute renal failure thirty years on. Quality Journal of Medicine 1990; 74: 1-2
  5. Macias WL. Choice of replacement fluid/dialysate anion in continuous renal replacement therapy. American Journal of Kidney Diseases 1996; 28: S15-S20
  6. Davenport A, Will E, Davison AM. The effect of lactate-buffered solutions on the acid-base status of patients with renal failure. Nephrology, Dialysis, Transplantation 1989; 4: 800-804
  7. Veech L. The untoward effects of the anions of dialysis fluid. Kidney International 1988; 34: 587-597
  8. Reynolds HN, Belzberg H, Connelly J. Hyperlactemia in patients undergoing continuous arteriovenous haemofiltration with dialysis. Critical Care Medicine 1990; 18: 582-587
  9. Gudis SM, Mangi S, Feinroth M, Rubin JE, Friedman EA, Berlyne GM. Rapid correction of severe lactic acidosis with massive isotonic bicarbonate infusion and simultaneous ultrafiltration. Nephron 1983; 33: 65-66,
  10. Vaziri ND, Ness R, Weilikson L, Barton C, Greep N. Bicarbonate-buffered peritoneal dialysis. An effective adjunct in the treatment of lactic acidosis. American Journal of Medicine 1979; 67: 392-396
  11. Barenbrock M, Hausberg M, Matzkies F, De La Motte S, Schaefer RM. Effects of bicarbonate- and lactate-buffered replacement fluids on cardiovascular outcome in CVVH patients. Kidney International 2000; 58: 1751-1757
  12. Connor H, Wood HF, Murray JG, Ledingham JG. Utilisation of L(+) lactate in patients with liver disease. Annual Nutrition and Metabolism 1982; 26: 308-314,
  13. Woll PF, Record CO. Lactate elimination in man: effects of lactate concentration and hepatic dysfunction. European Journal of Clinical Investigations 1979; 9: 397-404
  14. Kruse JA, Zaidi SAJ, Carlson RW. Significance of blood lactate levels in critically ill patients with liver disease. American Journal of Medicine 1987; 83: 77-82
  15. Nimmo GR, Grant IS, Mackenzie SJ. Lactate and acid base changes in the critically ill. Postgraduate Medical Journal 1991; 67(suppl I): S56-S61
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Continuous Renal Replacement Therapy

Luis Jorge Rodrigues Gaspar, Nelson Martins Moreira, Aires Ademar Moutinho, Paulo Jorge Moreira Pinto, Helder Br?zida Lima. Nephrology Department, Oporto, Portugal.

Address for correspondence
Alameda Prof. Hernani Monteiro
Hospital de St. João,
Nephrology Department,
4202-451 - Oporto
Portugal

Summary
Continuous Renal Replacement Therapy (CRRT) is frequently used in patients admitted to intensive care units with multiple organ failure and acute renal failure. These patients are prone to developing hypotension making it very difficult to use conventional haemodialysis for their treatment. When compared to conventional haemodialysis CRRT has obvious clinical advantages. These advantages are mostly due to slow volume and uraemic toxin removal leading to better haemodynamic tolerability for such patients. In our unit during the year 2000, 58 patients were submitted to CRRT: 14 of those patients underwent treatment with continuous veno-venous haemofiltration and 44 were submitted to continuous veno-venous haemodiafiltration. The mean patient age was 61,7 years (range: 20 - 87), 36 male and 22 females. Twenty patients (43,1%) had sepsis, 18 (31%) were post open-heart surgery, 7 (12%) had multiple organ failure, 4 (6,9%) were polytraumatised, 3 (5,2%) were post neurosurgery and 1 (1,8%) was a liver transplant patient. Despite the grave prognosis of these patients, 22 (37,8%) survived and 36 (62,2%) died. Of the patients that survived, 10 (17,2%) recovered renal function and 12 (20,6%) remained on a regular haemodialysis programme. The authors conclude that CRRT seems to be an alternative to conventional haemodialysis for the treatment of those patients with acute renal failure.

Key words
Continuous Renal Replacement Therapy
Haemofiltration
Haemodiafiltration

References

  1. Dauguirdas JT, Tood S. Handbook of dialysis - Library of Congress, Second Edition; 1998
  2. Thelan, LA, Davie, JK, Urden LD, Lough ME. Critical Care Nursing. Mosby Year Book, Inc., 1998
  3. Klee KM, Fouser L, Greenleaf K, Watkins SL. Continuous venovenous hemofiltration with and without dialysis in paediatric patients. ANNA Journal 1996; 23 (1)
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Early Management and Prevention of Acute Renal Failure (ARF)

P. Kalra, Consultant Nephrologist, Hope Hospital, Salford, UK

Address for correspondence
Dr. Philip A. Kalra, MA MBBChir FRCP MD
Department of Renal Medicine
Tel: 0044 161 787 5998
Fax: 0044 161 787 5342
E-mail: pkalra@hope.srht.nwest.nhs.uk

Summary
Despite major advances in nutritional support, membrane technology and dialytic techniques, the mortality of patients with acute renal failure (ARF) who require dialysis is still almost 50% (1). Increased patient age and co-morbidity confer a poorer prognosis, and the condition is certainly commoner in this patient group. Hence, one study showed that the age-related annual incidence of ARF increased from 17 per million in adults under 50 years to 949 per million in the 80-89 age group (2).

Over 60% of cases of ARF ultimately result from renal hypoperfusion and consequent intra-renal ischaemic damage, which leads to acute tubular necrosis (ATN) (3). Ischaemic ARF may thus result from a diversity of systemic and intra-renal circulatory stresses including acute losses of blood and extra-cellular fluids, from low cardiac output states such as following ischaemic or toxic myocardial damage, and even from drug-induced renal perfusion shutdown (ACE inhibitors, non-steroidal anti-inflammatory agents). Many cases of ARF have a multi-factorial aetiology (e.g. post-surgical sepsis with hypovolaemia, hypotension and injudicious antibiotic use), and these patients, who often have other organ failure, fit into the poorer prognostic category.

A large number of patients with ischaemic ARF pass through a phase of potentially reversible pre-renal oliguria; early recognition and prompt, appropriate treatment of these pre-renal factors can prevent progression to established ARF, with the genuine prospect of improved patient morbidity and mortality, and this is the main scope of this article. Early diagnosis in other patients with ARF, such as those with acute inflammatory renal disease (e.g. vasculitis) or urinary tract obstruction, will allow appropriate prompt treatment and the possibility for reversal of the ARF. The following account, which is composed of personal experience, that of colleagues, and the literature (1,4), is not intended to provide a comprehensive guide to the management of ARF, but seeks to highlight important common pitfalls and fundamental principles in the recognition and subsequent preventive treatment of these patients.

Key words
Acute renal failure
Prognosis
Treatment
Renal replacement therapy

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Editorial

N.Thomas

I am delighted to introduce this publication from EDTNA/ERCA. Our multi-disciplinary renal care association produces a monograph every few years, the aim being to focus on a topical subject that interests all members of the multi-professional team.

Acute renal failure (ARF) occurs frequently and often results in an unacceptably high morbidity and mortality (1). For some patients who acquire ARF whilst in hospital, and therefore need renal replacement therapy, mortality rates can exceed 50% (2).

This monograph explores the physiological, psychological and social aspects of ARF and discusses the role of the renal and intensive care teams in ARF management. Each paper is supported by relevant and up-to-date research. I am delighted that so many European experts have agreed to contribute and would like to acknowledge the hard work of the EDTNA/ERCA Journal Editor, Anna Marti i Monros and her team in producing such an excellent and much-needed publication.

There are still many unanswered questions concerning ARF. In particular, the potential impact of various renal replacement therapies on clinical outcomes needs to be better understood. There also continues much debate on the increasing role of the intensive care team - in many countries in Europe intensive-care physicians and nurses now care for patients with ARF. It is imperative that all those working in renal units keep up-to-date with new technologies in order that they can fully support role their colleagues in intensive care. This monograph aims to promote this partnership between renal and intensive care professionals.

EDTNA/ERCA continues to play a key role in influencing the quality of renal care in Europe. One of the strengths of the Association is that we provide our publications in seven languages. I hope that this EDTNA/ERCA monograph encourages critical reflection about care for those with ARF, and in some way helps towards improving morbidity and mortality in this often critically-ill group.

References

  1. Kelly KJ, Molitoris BA. Acute renal failure in the new millennium: time to consider combination therapy. Seminars in Nephrology 2000; Jan 20 (1): 4-19
  2. Karsou SA, Jaber BL, Pereira BJ. Impact of intermittent haemodialysis variables on clinical outcomes in acute renal failure. American Journal of Kidney Diseases 2000; May 35(5): 980-981
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EDTNA/ERCA Dialysis Technology Journal Club 2001/2 Summary

André Stragier, Journal Club Chair, Brussels, Belgium

We selected as 2001/2 Dialysis Technology Journal Club (JC) discussion paper: What is the replacement method of first choice for intensive care patients by Raymond Vanholder, Wim Van Biesen and Norbert Lameire from the University Hospital of Gent, Belgium; J Am Soc Nephrol 2001; 12: S40-S43.

Brief summary of this JC discussion paper:
Renal replacement therapy for the patient with acute renal failure in the Intensive Care Unit (ICU) can be offered in several formats: Intermittent Haemodialysis (IHD), Continuous Renal Replacement Therapy (CRRT) and Slow Low-Efficient Daily Dialysis (SLEDD). The only potential advantages of CRRT that stood the test of clinical evaluation (haemodynamic stability, correction of hypervolaemia and better solute removal) are provided equally by SLEDD. The latter strategy is less expensive because the infrastructure is the same as for IHD; furthermore, the patient is not continuously immobilised, which leaves time for other activities such as nursing care and technical investigations. SLEDD is relatively recent and clinical studies are still lacking. The authors support that SLEDD is a valuable alternative to the classical dialysis strategies, utilised in the intensive care patient.

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Effects of Different Doses in Continuous Veno-Venous Haemofiltration on Outcomes of Acute Renal Failure: a Prospective Randomised Trial

C. Ronco, R. Belomo, P. Homel, A. Brendolan, M. Dan, P. Piccinni, G. La Greca, Vicenza, Italy.

Key words
Acute renal failure
Trial
Haemofiltration

Biodata
Claudio Ronco graduated in Medicine at the University of Padua in 1976. In 1979, he achieved a Specialization Diploma in Medical Nephrology at the postgraduate school of internal medicine of the University of Padua, and in 1989, he achieved a Specialization Diploma in Paediatric Nephrology at the University of Naples. Claudio is a member of many societies including the Italian Society of Nephrology and the International Society for Peritoneal Dialysis

Address for correspondence
Claudio Ronco,
MD, Department of Nephrology, St. Bortolo Hospital,
Viale Rodolfi,
36100 Vicenza,
Italy
Tel +390444993869
Fax +390444993949
e-mail cronco@goldnet.it

Summary
Background Continuous veno-venous haemofiltration is increasingly used to treat acute renal failure in critically ill patients, but a clear definition of an adequate treatment dose has not been established. We undertook a prospective randomised study of the impact of different ultrafiltration doses in continuous renal replacement therapy on survival.

Methods We enrolled 425 patients, with a mean age of 61 years, in intensive care who had acute renal failure. Patients were randomly assigned ultrafiltration at 20 mL h~1 kg~ - (group 1, n=146), 35 mL h~1 kg~ - (group 2, n=139), or 45 mL h 1 kg - (group 3, n=140). The primary endpoint was survival at 15 days after stopping haemofiltration. We also assessed recovery of renal function and frequency of complications during treatment. Analysis was by intention to treat.

Results Survival in group 1 was significantly lower than in groups 2 (p=0.0007) and 3 (p=00013). Survival in groups 2 and 3 did not differ significantly (p=0.87). Adjustment for possible confounding factors did not change the pattern of differences among the groups. Survivors in all groups had lower concentrations of blood urea nitrogen before continuous haemofiltration was started than non-survivors. 95%, 92% and 90% of survivors in groups 1, 2 and 3, respectively, had full recovery of renal function. The frequency of complications was similarly low in all groups.

Interpretation Mortality among these critically ill patients was high, but increase in the rate of ultrafiltration improved survival significantly. We recommend that ultrafiltration should be prescribed according to patient's bodyweight and should reach at least 35 mL h~1 kg1.

References

  1. Nissenson AR. Acute renal failure: definition and pathogenesis. Kidney International 1998; 53 (Suppl 66): S7 - lO.
  2. Briglia A, Paganini EP, Acute renal failure in the intensive care unit: therapy overview, patient risk stratification, complications of renal replacement, and special circumstances, Clinical Chest Medicine 1999; 20: 347-66.
  3. Schetz MRC. Classical and alternative indications for continuous renal replacement therapy. Kidney International 1998; 53 (Suppl 66): S 129 - 32.
  4. Bellomo R, Mansfield D, Rumble S, Shapiro J, Parkin G, Boyce N. A comparison of conventional dialytic therapy and acute continuous hemodiafiltration in the management of acute renal failure in the critically ill. Renal Failure 1993; 15: 595 - 602.
  5. Ronco C, Bellomo R, eds. Critical care nephrology. Dordrecht, Netherlands: Kluwer Academic Publishers, 1998,
  6. Jones CH, Richardson D, Goutcher E, et al. Continuous venovenous high-flux dialysis in multiorgan failure: a 5 year single center experience. American Journal of Kidney Diseases 1998; 31: 227 - 33.
  7. Bellomo R, Ronco C. Continuous renal replacement therapy in the intensive care unit. International Care Medicine 1999; 25: 781 - 89.
  8. Clark WR, Mueller BA, Kraus MA, Macias WL. Extracorporeal therapy requirements for patients with acute renal failure, Journal of the American Society of Nephrology 1997; 8: 804 - 12.
  9. Paganini EP, Tapolyai M, Goormastic M, et al. Establishing a dialysis therapy/patient outcome link in intensive care unit acute dialysis for patients with acute renal failure. American Journal of Kidney Diseases 1996; 28 (Suppl 3): S81 - 89
  10. Silvester W. Outcome studies of continuous renal replacement therapy in the intensive care unit. Kidney International 1998; 53 (Suppl 66): S138 - 41.
  11. Bellomo R, Ronco C. Indications and criteria for initiating renal replacement therapy in the intensive care unit. Kidney International 1998; 53 (Suppl 66): S 106 - 09.
  12. van Bommell EFH, Bovy ND, Hop WCJ, Bruining HA, Weimar W. Use of APACHE 11 classification to evaluate outcome and response to therapy in acute renal failure patients in a surgical intensive care unit. Renal Failure 1995; 17: 731 - 42,
  13. Parker RA, Tolkoff-Ruhin HJ, Wingard RL, Hakim R. Survival of dialysis dependent acute renal failure (ARF) patients predicted by APACHE fl (API!) score, Journal of the American Society of Nephrology 1994; 5: 402 (abstr).
  14. Bosch JP, Ronco C. Continuous arteriovenous haemofiltration (CAVH) and other continuous replacement therapies: operational characteristics and clinical use. In: Maher JF, ed. Replacement of renal function by dialysis. Dordrecht, Netherlands: Kluwer Academic Publishers, 1989: 347 - 59.
  15. Amoroso P, Greenwood R: Acute renal failure: survey of the management of acute renal failure in the critically ill in England and Wales. British Journal of Intensive Care 1992; 2: 92 - 94.
  16. Stevens P, Rainford D. Continuous renal replacement therapy: impact on the management of acute renal failure. British Journal of lntensive Care 1992; 2: 361 - 69.
  17. Gotch FA, Sargent JA. A mechanistic analysis of the National Cooperative Dialysis Study (NCDS). Kidney International 1985; 28: 526-34.
  18. Stork M, Hard WH, Zimmerer E, In Thorn D. Comparison of pump driven and spontaneous continuous haemofiltration in postoperative acute renal failure. Lancet 1991; 337: 452 - 55.
  19. Paganini EP, Halstenberg WK, Goormastic M. Risk modelling in acute renal failure requiring dialysis: the introduction of a new model. Clinical Nephrology 1996; 46: 206-11.
  20. Swartz RD, Messana JM, Orzol S, Port FK. Comparing continuous haemofiltration with haemodialysis in patients with severe acute renal failure. American Journal of Kidney Diseases 1999; 34:424-32.
  21. Dourna CE, Rodckop WK, van der Meulen JHP, et al. Predicting mortality in intensive care patients with acute renal failure treated with dialysis. Journal of the American Society of Nephrology l997;8: 111 - 17.
  22. Halstenberg WK, Goormastic M. Paganini EP. Validity of four models for predicting outcome in critically ill acute renal failure patients. Clinical Nephrology 1997; 47: 8 1-86.
  23. Clark WR, Murphy MI, Alaka KJ, Mueller BA, Pastan SO, Macias WL. Urea kinetics during continuous haemofiltration. ASAIOJ 1992; 38: M664 - 67.
  24. Tattersall J, Farrington K, Greenwood R. Adequacy of dialysis. In: Davison AM, ed. Oxford textbook of clinical nephrology. Oxford: Oxford University Press, 1998: 2075 - 87.
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Ethical Aspects of Withdrawing/Withholding Renal Replacement Therapies on Patients in Acute Renal Failure in an Intensive Care Unit

H. Draper, Birmingham University, UK.

Biodata
Heather Draper (PhD) is a Senior Lecturer in Biomedical Ethics at Birmingham University, UK.

Address for correspondence
Dr Heather Draper
The Centre for Biomedical Ethics
The Department of Primary Care and General Practice
Primary care and Teaching Resources Building
The University of Birmingham
Edgbaston
Birmingham
B15 2 TT
UK
Email: h.draper@bham.ac.uk

Abstract
The majority of patients being treated for acute renal failure in intensive care units have multiple medical problems. Accordingly, the withdrawal of renal replacements therapies should be considered as part of a general decision about whether to initiate or continue with treatment per se. Several guidelines on withdrawing and withholding therapy have been produced and some common themes emerge: concerns to avoid euthanasia, potential for benefit, patient consent (shared decision-making), team consensus/decision-making, the provision of appropriate palliative care and resource implications. Each of these is considered in turn, although the word limit for this paper does not permit detailed exposition.

Key words
Ethics
Treatment withdrawal
Withholding treatment
Renal replacement therapies
Acute renal failure

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Importance of Increased Ultrafiltration Volume and Impact on Mortality: Sepsis and Cytokine Story and the Role of CVVH

C. Ronco, MD1, Z. Ricci, MD., R. Bellomo, MD2
1) Department of Nephrology, St. Bortolo Hospital,Vicenza - Italy
2) Intensive Care Unit, Austin & Repatriation Medical Center, Heidelberg, Victoria, Australia

Summary
There is growing interest in extracorporeal blood purification therapies (EBPT) as adjuvants in the complex therapy of sepsis and multiple organ dysfunction syndrome (MODS). Nowadays the only routinely used purification technique is renal replacement therapy (RRT) during acute renal failure (ARF), one of almost inevitable and deadly component of MODS. RRT has been the first and still is the most used and effective type of EBPT. Evidence is growing about its ability to maintain homeostatic balance in critically ill patients, and specifically in septic patients with MODS. Clinical trials have been recently designed to modify or improve these therapies. In detail, the following issues have been currently addressed: effects on blood purification provided by different therapies, adequacy of prescription and delivery of therapy, toxins and solutes to be removed with these techniques. Based on these speculations we will briefly review the current understanding of these issues and the rational for application of RRT in the intensive care unit (ICU). In particular, we will focus on the importance of increased ultrafiltration volume and its impact on mortality in the general ICU population and in septic patients.

Address for correspondence
Claudio Ronco,
MD, Department of Nephrology, St. Bortolo Hospital,
Viale Rodolfi,
36100 Vicenza,
Italy
Tel +390444993869
Fax +390444993949
e-mail cronco@goldnet.it

Key words
Ultrafiltration
Renal Replacement Therapy
Cytokine
Mortality

Biodata
Claudio Ronco graduated in Medicine at the University of Padua in 1976. In 1979, he achieved a Specialization Diploma in Medical Nephrology at the postgraduate school of internal medicine of the University of Padua, and in 1989, he achieved a Specialization Diploma in Paediatric Nephrology at the University of Naples. Claudio is a member of many societies including the Italian Society of Nephrology and the International Society for Peritoneal Dialysis

References

  1. Vincent JL. Incidence of Acute Renal Failure in the Intensive Care Unit. Contribution to Nephrology 2001; 132:1-6.
  2. Nissenson AR. Acute renal failure: definition and pathogenesis. Kidney International 1998; 53 (Suppl 66):S7-10.
  3. Gotch FA, Sargent JA. A mechanistic analysis of the National Cooperative Dialysis Study (NCDS). Kidney International 1985; 28:526-534.
  4. Stork M, Hartl WH, Zimmerer E, Inthorn D. Comparison of pump driven and spontaneous continuous haemofiltration in postoperative acute renal failure. Lancet 1991; 337:452-5.
  5. Paganini EP, Kanagasundaram NS, Larive B, Greene T. Prescription of adequate renal replacement in critically ill patient. Blood Purification 2001;19:238-244
  6. Ronco C, Bellomo R, Homel P, Brendolan A, Dan M, Piccinni P, La Greca G. Effect of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 2000; 356:26-30
  7. Bosch JP, Ronco C. Continuous Arteriovenous Haemofiltration (CAVH) and Other Continuous Replacement Therapies: Operational Characteristics and Clinical Use. In: Replacement of Renal Function by Dialysis. Edited by John F. Maher, Kluwer Acc. Publishers, Dordrecht, The Netherlands, 1989; pp. 347-359.
  8. Amoroso P, Greenwood R: Acute renal failure. Survey of the management of acute renal failure in the critically ill in England and Wales. British Journal of Intensive Care 1992; 2:92-94.
  9. Stevens P, Rainford D. Continuous renal replacement therapy. Impact on the management of acute renal failure. British Journal of Intensive Care 1992; 2: 361-369.
  10. Gotch FA. Daily haemodialysis is a complex therapy with unproven benefits. Blood Purification 2001;19:211-16
  11. Uchino S, Bellomo R, Ronco C. Intermittent versus continuous renal replacement therapy in the ICU: impact on electrolyte and acid-base balance. Intensive Care Medicine 2001; 27:1037-43
  12. Groodendorst AF, van Bommel EFH, van der Hoven B, et al. High volume haemofiltration improves haemodynamics of endotoxin induced shock in the pig. Journal of Critical Care 1992;7:67-75
  13. Rogiers P, Zhang H, Smail N, Pauwels D, Vincent JL. Continuous veno-venous haemofiltration improves cardiac performance by mechanism other then tumor necrosis factor alpha attenuation during endotoxic shock. Critical Care Medicine 1999;27:1848-55
  14. Bellomo R, Kellum JA, Ghandi CR, Pinsky MR. The effect of intensive plasma water exchange by haemofiltration on haemodynamics and soluble mediators in canine endotoxemia. American Journal of Respiratory Critical Care Medicine 2000;161:1429-36
  15. Yekebas EF, Eisenberger CF, Ohnesorge H, et al. Attenuation of sepsis related immunoparalysis by continuous veno-venous haemofiltration in experimental porcine pancreatitis. Critical Care Medicine 2001;29:1423-30
  16. Journois D, Israel Biet D, Pouard P, et al. High volume, zero-balanced haemofiltration to reduce delayed inflammatory response to cardiopulmonary bypass in children. Anesthesiology 1996; 85:965-76
  17. Lonneman G, Bechstein M, Linneweber S, Burg M, Koch KM. Tumor necrosis factor alpha during continuous high-flux haemodialysis in sepsis with acute renal failure. Kidney International 1999;56:S84-S87
  18. Oudemans-van Straaten HM, Bosman RJ, van der Spoel JI, Zandstra DF. Outcome of critically ill patients treated with high volume haemofiltration: a prospective cohort analysis. Intensive Care Medicine 1999;25:814-821
  19. Honore PM, Jamez J, Wauthier M, et al. Prospective evaluation of short-term, high volume isovolemic haemofiltration on the hemodynamic course and outcome in patients with intractable circulatory failure resulting from septic shock. Critical Care Medicine 2000;28(11):3581-7
  20. Cole L, Bellomo R, Journois D, Davenport P, Baldwin I, Tipping P. High-volume haemofiltration in human septic shock: Intensive Care Medicine 2001; 27:978-86
  21. Brendolan A, Bellomo R, Tetta C, et al. Coupled plasma filtration adsorption in the treatment of septic shock. Contribution to Nephrology 2001;132:383-90
  22. Brendolan A, Irone M, Digito A, et al. Coupled plasma filtration adsorption technique in sepsis associated acute renal failure: haemodynamic effects. Journal of the American Society of Nephrology 1998;9:127A
  23. Ronco C, Brendolan A, Dan M, et al. Adsorption in sepsis. Kidney International 2000;58 suppl 76:S148-55
  24. Tetta C, Gianotti L, Cavaillon JM, et al. Coupled plasma filtration adsorption in a rabbit model of endotoxic shock. Critical Care Medicine 2000;28:1526-33
  25. Berlot G, Lucangelo U, Galimberti G, Sganga G. Plasmapheresis in sepsis. Contribution to Nephrology 2001;132:391-9
  26. Tetsunosuke Kunitomo, Hisataka Shoji. Endotoxin removal by Toraymixin. Contribution to Nephrology 2001;132:415-20
  27. Kellum JA, Mehta RL, Ronco C. Acute Dialysis Quality Initiative (ADQI). Contribution to Nephrology 132: 258-265, 2001.
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Nursing Care Plans for Renal Patients Following the Krohwinkel Model

P. Fischer, Stuttgart, Germany.

Biodata
Patricia Fischer qualified as a nurse in 1981. She has had experience in Neurosurgery, Mandible surgery, General Medicine and Intensive Care. She is an active member of DBfK (German Union of Nursing) LV Baden Württemberg.

Key words
Roper
Care plan
Nursing Objectives
Model of nursing

Address for correspondence
Patricia Fischer
Krapfenreuter Str. 28
D- 73061 Ebersbach
Germany
Phone +49 (0)7163 - 52225
Fax +49 (0)7163 - 531651
E-mail p-g.fischer@t-online.de

Bibliography

  1. Günter Schönweiss: Dialyse Fibel, abakiss Verlag Bad Kissingen, 2. Auflage 1996
  2. W.J. Kox, U.Rohr, H.Wauer: Praktische Anwendung, Anästhesiologie und Intensivmedizin, Perimed-Spitta Verlag Balingen, Heft 10/95, Seite 277-281
  3. W.Druml: Einfluß der kontinuierlichen Nierenersatztherapie auf den Metabolismus, Dialyse-Journal, Papst Science Publishers Lengenried, Heft 50/95, Seite 46-48
  4. H. Buchardi: Kontinuierliche Hämofiltration als Behandlungsverfahren in der Intensivmedizin, Intensiv- und Notfallbehandlung, Jahrgang 18, Nr. 3/93, Seite 111 - 118
  5. H. Buchardi: Neue Nierenersatzverfahren - Differentialindikation, Intensiv, Georg Thieme Verlag Stuttgart, Heft 1/93, Seite 10-15
  6. N.Mertes / A.E.Lison: Kontinuierliche Extrakorpurale Blutreinigunsverfahren während Intensivbehandlung - Praktischer Leitfaden, Wolfgang Papst Verlag Lengerich, Berlin ..., Grundwerk 1992
  7. Diverses Prospekt- und Infomaterial zum Thema Nierenersatzverfahren und Filter der Firmen Hospal, Fresenius, VMP, Gambro
  8. N. Braun: Hämofiltration, Hämodiafiltration, Biofiltration Teil 2, Krankenpflegejournal 33, 1995, S. 198 - 205
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Nutritional aspects of Acute Renal Failure

M. Hoogerwerf, Dietetic Department, Amersfoort, Netherlands.

Key Words
Renal failure
Nutrition
Malnutrition

Summary
The patient with acute renal failure is a very ill patient suffering from high urea levels causing poor appetite, nausea and vomiting. These patients are usually treated with a low sodium, low protein and, if the potassium in the blood is high, with a low potassium diet (1). This paper discusses whether or not this is the correct treatment.

The symptoms of high urea levels in the blood together with increased needs for energy and protein makes it very hard to prevent the patient becoming malnourished. Often energy-enriched drinks are necessary to achieve recommendations and it is prudent to let the patient eat and drink what they desire. By calculating the energy and protein needs and comparing these with the intake and the state of illness and by following the patients body weight over time we can obtain information about the state of nourishment. When we alter the food that's offered we achieve better intake and reduce the risk of malnourishment.

Biodata
Monique Hoogerwerf has been a dietician for twelve years and has worked for three years with renal failure patients. She is on the board of the Dieticians Kidney Disease of the Netherlands.

Address for correspondence
Monique Hoogerwerf
Dietetic department
Eemland Hospital
Postbus 1502, 3800 BM Amersfoort
Netherlands
E-mail: m.hoogerwerf@zkh-eemland.nl

References

  1. Diëtisten Nierziekten Nederland. Behandelingsprotocolen. Januari 1995
  2. Klinische Voeding 2000:71-95
  3. Allison SP. The uses and limitations of nutritional support. Clinical Nutrition 1992; 11:319-330
  4. Hill GL Body composition research: Implications for the practice of clinical nutrition. JPEN 1992; 16:197-218
  5. Kotler DP et al. Magnitude of body cell mass depletion and timing of death from wasting in AIDS. American Journal of Clinical Nutrition 1989; 50:444-447
  6. Studley HO. Percentage weight loss. A basic indicator of surgical risk inpatients with chronic peptic ulcer. JAMA 1936; 106:458-460
  7. Shaw JHF et al. Whole body protein kinetics in severely septic patients. The response to glucose and parenteral nutrition. Ann Surg 1987; 205:288-299
  8. EDTNA/ERCA Journal XXVII, nr. 2:102-105
  9. Informatorium voor voeding en diëtetiek juni 1997
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The effects of Acute Renal Failure on the family

C. Ashwarden, Cookham Berks, UK.

Summary
This paper will explore the effects of Acute Renal Failure (ARF) on the family of the patient. The patient's needs are the concern of the health care team and are more medically orientated than those of the family, whose needs are prevailingly social ones. However, the family's reactions do affect the patient and his/her response to their illness. The diagnosis of any major illness is devastating for the patient and his/her family, and in discussing ARF and its effects, it is possible to realise the common needs of the relatives of all acutely sick people. There is little written about the family's needs when ARF is diagnosed because of the commonalties with the diagnosis of any sudden critical illness. However it is in the relationships between the families and the specialist renal nurse where the differences lie. The partnership which develops in chronic renal care between the renal nurse and his/her patient translates onto the Acute unit and makes the care that the specialist Acute nurse provides different to other wards in a hospital. On diagnosis, the patient will be treated either on an Intensive Care Unit or in the acute haemodialysis unit depending on the causes of the renal failure and the co-morbidities. The personnel treating the patient will differ depending where the treatment is delivered; but wherever the patient finds themselves the needs of the family are generally the same (1). There is much debate about where is the best place to treat people with ARF (2) but most patients are moved to the Acute haemodialysis ward as soon as possible, where the specialist nursing staff have great influence over the treatment and care of the patient. It is here, where the expert nurse and her/his skills are most in evidence and the skills of the nurse are vital, as s/he will spend the most time with the patient (3). It is the time spent during treatment when the family can relate to one caregiver and relationships develop.

Key words
Acute Renal Failure
Family
Nurse
Support

Address for correspondence
Cordelia Ashwanden.
Butts Legh, School Lane,
Cookham Berks SL6 9QJ
UK.

Biodata
Cordelia Ashwanden, MSc. BSc. Adult Ed.Cert. RGN is now in her final year at Southampton University finishing a PhD in Renal Nursing. She was manager of a Haemodialysis unit in the UK for 13 years, and has been in renal nursing for over 30 years

References

  1. Auer J. The Psychological Impact of Treatment. In Smith Ed. Renal Nursing. Baillière Tindall, London UK 1997.
  2. MacLeod A. Acute Renal Failure E-Mail mmd175@abdn.ac.uk 2001.
  3. The Kidney Alliance. End Stage Renal Failure - A Framework for Planning and Service Delivery. Published by The Kidney Alliance 2001 p50.
  4. Davidson A. Guideline for the management of acute renal failure. Nephrology, Dialysis, Transplantation 2001; 16:1535
  5. Herth K. Fostering Hope in terminally ill people. Journal of Advanced Nursing 1990; 15 (11):1250-9.
  6. Buckman R. How to Break Bad News. Macmillan Publishers Ltd. London UK 1992.
  7. Cassell E. The Nature of Suffering and the Goals of Medicine. Oxford University Press, New York USA 1991.
  8. The Kidney Alliance. End Stage Renal Failure - A Framework for Planning and Service Delivery. Published by The Kidney Alliance 2001.
  9. Renal Association Report. 2nd Edition. Treatment of adult patients with renal failure. The Laverham Press Ltd. Suffolk, UK. 1997.
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Vascular Access in Acute Renal Failure

J.P. Van Waeleghem, Nephrology-Hypertension Department, Antwerp, Belgium

Address for correspondence
J.P. Van Waeleghem
Nephrology-Hypertension Department
University Hospital Antwerp
Belgium

Biodata
Jean-Pierre Van Waeleghem first commenced working in haemodialysis in 1965 as a graduate nurse at the University of Gent. He has been the Nephrology Nurse Manager at the Nephrology-Hypertension Department of the University Hospital Antwerp since 1979. He is a past President of EDTNA/ERCA and has had various roles during his 30 years of active participation in the Association. Jean-Pierre is one of the directors and treasurer of the World Foundation for Renal Care. At national level, he is the President of the Flemish association for Nephrology Nurses, ORPADT.

Key words
Vascular access
Acute renal failure
Catheters

Summary
Today, central venous access catheters play an important role in the treatment and management of many dialysis patients. Their use and care may influence the patient's overall outcome. Therefore, it is critical to have a thorough knowledge of the vascular anatomy, types of catheters, placement techniques and maintenance and management of complications. The incidence nowadays of acute renal failure in intensive care patients is reported as high as 25%. Acute renal failure is one of the few causes of organ failure in which complete recovery is possible, provided the patient survives the associated comorbid conditions. There are various extracorporeal dialysis techniques available to threat this category of patients using mostly a central dialysis catheter as vascular access. It is important to select carefully the type of catheter and to create a specific vascular access system in order to be able to perform the selected dialysis technique in the most optimal efficient conditions. Any inadequacies of access will create dialysis insufficiency leading to more comorbid conditions and even higher mortality.

In this article, we will describe the different possibilities as well as the nursing management of that type of vascular access in patients with acute renal failure.

Bibliography

  1. Patel NH, Revanur VK, Khanna A, Hodges Ch, Jindal RM. Vascular access for /hemodialysis: an in-depth review. Journal of Nephrology 2001; 14: 146-56
  2. Bander SJ, Schwab SJ. Central venous angio access for hemodialysis and its complications. Seminars in Dialysis 1992; 5: 121
  3. Little MA, Conlon PJ, Walshe JJ. Access recirculation in temporary hemodialysis catheters as measured by the saline dilution technique. American Journal of Kidney Diseases 2000; 36: 1135
  4. Quinton W, Dillard D, Scribner BH. Cannulation of blood vessels to prolong hemodialysis. Trans ASAIO 1960; 6: 104
  5. Kairaitis LK, Gottlieb T. Outcome and complications of temporary haemodialysis catheters. Nephrology, Dialysis, Transplantation 1999; 14: 1710
  6. Butterly DW, Schwab SJ. Acute hemodialysis vascular access. Up-To-Date 2001.
  7. Fuchs S., Pollak A., Gilon D. Central venous catheter mechanical irritation of the right atrial free Wall: A cause for thrombus formation. Cardiology 2001; 91: 169
  8. Cox K, Vesely TM, Windus DW, Pilgram TK. The utility of brushing dysfunctional hemodialysis catheters. Journal of Vascular Intervention and Radiology 2000; 11: 979
  9. Twardowski ZJ. Stepwise anticoagulation with warfarin for prevention of intravenous catheter thrombosis. Hemodialysis International 2000; 4: 237
  10. Beathard GA. Thrombosis associated with chronic hemodialysis vascular access: Catheters. Up-To-Date 2001.
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Who Should Manage Continuous Renal Replacement in the Intensive Care Setting? A Nursing Viewpoint.

R. K. Martin, University of California, California, USA

Summary
Since its inception, continuous renal replacement therapy (CRRT) has been performed in critical care units with or without the involvement of nephrology nursing support (1,2). It is apparent that the issue of providing care to patients requiring this therapy is not so much a debate on the nursing control of CRRT, but a focused discussion on the nursing management and delivery of care to the patient receiving CRRT in the intensive care setting. Although the choice of a nursing care model for CRRT is dependent on many clinical and organizational factors, the use of one nursing specialty to deliver CRRT care can leave gaps in practice. The Joint or Collaborative Nephrology/critical care nursing model brings the highest level of nursing expertise to the bedside. The joint model tends to promote collaboration between two distinct nursing specialties, with opportunities for setting joint standards and promoting research. With this in mind, this discussion will examine some of the factors affecting structuring of nursing care, describe nursing models currently in use, compare the attributes of each, and conclude which model is preferred for the delivery of nursing care for CRRT.

Keywords
Intensive care
Nurse
Continuous renal replacement

Address for correspondence:
Rhonda K. Martin, RN, MS, MLT (ASCP), CCRN, CNS/ANP-C
University of California,
San Diego Medical Center
200 West Arbor Drive, MCH 8401
San Diego, CA 92103

References

  1. Dracup K, Bryan-Brown C. On notebooks and trust. American Journal of Critical Care 2002; 11(2): 96-100
  2. Firth J. Renal Replacement Therapy on the Intensive Care Unit. New York: Oxford University Press, 1993.
  3. Strohstein B, Caruso D, Greene K. Continuous venovenous hemodialysis. American Journal of Critical Care 1994; 3(2): 92-99
  4. Baldwin I, Elderkin T. Continuous Hemofiltration: Nursing perspectives in critical care. New Horizons 1995; 3(4): 738-747
  5. Price C. An update on continuous renal replacement therapy. AACN Clinical Issues 1992; 3(3): 597-604
  6. Price C, Compton A, Martin R. Continuous renal replacement therapy. Standards of Clinical Practice For Nephrology Nursing. American Nephrology Nurses' Association, 1999.
  7. Whittaker A. Patients with acute renal failure. In Clochesy J, et. al. Critical Care Nursing. Philadelphia: W. B. Saunders, 899-901, 1993
  8. Marti R, Jurschak J. Nursing management of continuous renal replacement therapy. Seminars in Dialysis 1996; 9(2): 192-199
  9. Mehta R, Martin R. Initiating and implementing a continuous renal replacement therapy program. Seminars in Dialysis 1996; 9(2): 80-87
  10. Henneman E. Nurse-physician collaboration: Beyond compromise. The Third Annual Advanced Practice Nursing Symposium, Long Beach, CA, 1997.
  11. Koerne B, Armstrong D. Collaborative practice cuts cost of patient care: study. Hospitals 1984; 58(10)
  12. Koerner B, Cohen J, Armstrong D. Collaborative practice and patient satisfaction. Evaluation of Health Profession 1985; 8: 299-321,
  13. Shortell S, et. al. The performance of intensive care units: Does good management make a difference? Medical Care 1994; 32:508-525
  14. Spross J. The CNS as collaborator. The Clinical Nurse Specialist in Theory and Practice. W. B. Saunders Co., Philadelphia, 1989.
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