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Background: We performed a systematic review of randomized controlled trials (RCTs) comparing hemodialysis (HD), hemofiltration (HF), hemodiafiltration (HDF), and acetate-free biofiltration (AFB) in the treatment of patients with end-stage renal disease to assess their clinical effectiveness., Methods: The Cochrane CENTRAL Registry, MEDLINE, EMBASE, CINAHL, the American College of Physicians Database, Database of Abstracts of Reviews of Effectiveness, and reference lists were searched for randomized trials of HF, HDF, and AFB compared with HD; HDF compared with AFB; and HF compared with HDF. Two reviewers extracted data for all-cause mortality; hypotension, headache, nausea, vomiting, and any other adverse symptoms; quality of life (QoL); hospitalization; dialysis adequacy; and end-of-treatment beta 2 -microglobulin levels. Analysis was by means of a random-effects model, and results are expressed as relative risk (RR) and weighted mean difference (WMD) with 95% confidence intervals (CIs)., Results: Eighteen eligible trials (588 patients) were identified. HDF was associated with significantly greater mortality risk than HD (4 trials, 326 patients; RR, 3.52; 95% CI, 1.37 to 9.47). Risk for mortality was not different among the other comparisons. Risks for hypotension episodes and dialysis-related symptoms were not significantly different with HD, HF, HDF, and AFB (18 trials, 583 patients). QoL, assessed by using an unvalidated scoring tool, appeared to be significantly improved in patients on HDF therapy than those on HD therapy (1 trial, 67 patients; WMD, 0.6; 95% CI, 0.3 to 0.9), but this was not evident when validated QoL assessment tools were used. Use of AFB compared with HDF was not associated with a significant difference in risk for hospitalization (1 trial, 11 patients; WMD, -0.45; 95% CI, -1.42 to 0.52). HDF in comparison to HD did not reduce the risk for carpal tunnel syndrome (1 trial, 67 patients; RR, 2.04; 95% CI, 0.59 to 7.00). Kt/V was significantly different with HDF compared with HD (3 trials, 124 patients; WMD, 0.14; 95% CI, 0.05 to 0.22). No other substantial data for these interventions and their impact on major patient-centered outcomes were available., Conclusion: The trials assessed were not powered adequately and had suboptimal method quality. It is not possible on the basis of effectiveness to prefer one extracorporeal renal replacement therapy modality to the other for end-stage kidney disease because significant differences in clinically important outcomes have not been shown by available published RCTs.

The elimination of the piperacillin/tazobactam combination was studied in six patients with acute renal failure undergoing either continuous venovenous haemofiltration (CVVH) or continuous venovenous haemodiafiltration (CVVHDF) at 1 L/h and 2 L/h for 12 h. Piperacillin 4 g/tazobactam 0.5 g was given iv on three successive treatment periods and their concentrations in plasma, ultrafiltrate/dialysate and urine were determined for 12 h after each dose. The elimination half-life of piperacillin during CVVH (7.7 +/- 2.3 h; mean +/- s.d.) was significantly longer than during CVVHDF 1 L/h (6.7 +/- 1.9 h) or 2 L/h (6.1 +/- 2.0 h) (P< 0.05). Corresponding values for tazobactam were 13.9 +/- 3.9, 11.6 +/- 3.3 and 9.4 +/- 2.4 h, respectively (P< 0.05). Total piperacillin clearance during CVVH (3.89 +/- 1.23 L/h) was significantly lower than during CVVHDF 1 L/h (5.06 +/- 1.68 L/h) or 2 L/h (5.48 +/- 2.11 L/h) (P< 0.05). The corresponding tazobactam clearance values were 2.42 +/- 0.75, 3.13 +/- 0.66 and 3.75 +/- 1.43 L/h, respectively. The mean 12 h elimination of piperacillin and tazobactam in ultrafiltrate/dialysate was 29% and 37% during CVVH, 42% and 57% during CVVHDF (1 L/h), and 46% and 69% during CVVHDF (2 L/h). We recommend 8 hourly dosing of patients with renal failure on CVVH or CVVHDF with dialysis flow rates of 1 or 2 L/h treated with piperacillin 4 g/tazobactam 0.5 g.

Hypothesis: Amino acid (AA) loss is not equivalent on continuous venovenous hemofiltration (CVVH) compared with continuous venovenous hemodiafiltration (CVVHD). Amino acid supplementation may be necessary to adjust for a greater clearance on CVVH to maintain nitrogen balance similar to that of CVVHD., Objective: To compare AA losses and nitrogen balance between CVVH and CVVHD in children with acute renal failure., Setting: Pediatric patients in the pediatric intensive care unit of a tertiary referral center., Design: Prospective randomized crossover study in consecutive children who required hemofiltration., Patients: A total of 12 plasma clearance studies for AA and urea, consisting of 24-hr collections of ultrafiltrate and urine for nitrogen balance, was performed on six patients during CVVH and CVVHD. Patients received total parenteral nutrition (TPN) with caloric intake 20% to 30% above their resting energy expenditure measured by indirect calorimetry and 1.5 g/kg/day protein of TPN. Study conditions were comprised of 2 L/hr/1.73 m2 of dialysate or prefiltered replacement fluid and hemofilter flow rates of 4 mL/kg/min were maintained for all patients., Methods and Main Results: Amino acid clearances were greater on CVVH than CWHD, except for glutamic acid, where clearance was 6.73+/-2.31 (SEM) mL/min/1.73 m2 on CVVH and 7.59+/-2.79 mL/min/1.73 m2 for CVVHD (NS). The clearance difference between the two modalities was 30%. Urea clearance was equivalent (30.1+/-1.74 mL/min/1.73 m2 and 29.0+/-.97 mL/min/1.73 m2) for CVVH and CVVHD, respectively. Amino acid loss on CVVH and CVVHD was similar (12.50+/-1.29 g/day/1.73 m2 vs. 11.61+/-1.86 g/day/1.73 m2, respectively), representing 12% and 11%, respectively, of the daily protein intake. The catabolic state, as measured by urea nitrogen appearance, was high for all patients during the 48-hr study period with a mean of 291 mg/kg/day during CVVH, and 245 mg/kg/day for CVVHD. Nitrogen balance varied from a negative 12.95 g/day/1.73 m2 to a positive 4.93 g/day/1.73 m2 on CVVH and a negative 7.69 g/day/1.73 m2 to a positive 5.50 g/day/1.73 m2 on CVVHD., Conclusions: Clearance of AA is greater on CVVH than on CVVHD, but no significant difference in AA loss was present between the two therapies. Nitrogen balance often is not met on either therapy when a standard 1.5 g/kg/day protein and a resting energy expenditure of 120% to 130% of calories is delivered by TPN.

Background: Several methods of dialysis are currently available. The choice of whether to use one of them is determined by multiple factors that are analyzed in this study., Patients and Methods: One hundred and twenty-six children (mean age: 48 +/- 6 months) were treated in 29 French intensive care units and/or departments of nephrology during 1991. The underlying diseases were: hemolytic-uremic syndrome (HUS) in 28% of patients, other renal diseases in 6%, metabolic diseases in 8%, septic shock in 8%, cardiogenic shock in 9%, hypovolemic shock in 10%, multiple organ failure in 7%, acute liver disease in 9% and other diseases in 15%., Results: Peritoneal dialysis (PD) was the favorite method in patients less than 10 years: intermittent hemodialysis (IHD), continuous hemofiltration and hemodiafiltration, (HF, HDF) were preferentially used above this age. PD was used in 85% of HUS, 58% of shocks and 50% of metabolic diseases. Sixty percent of acute renal diseases other than HUS were treated by IHD. HF and HDF were used in 66% of acute liver diseases and 42% of shocks. Overall mortality was 40% but no death could be directly ascribed to the different methods of dialysis., Conclusion: The choice of method depends on the type of underlying disease, age of the patient but also the equipment of centers. Progress in evaluating indications and results of the different methods of dialysis are necessary.