Distinction between induction and maintenance dosing in continuous renal replacement therapy.docVIP

MacLaren Critical Care 2011,15:419 /content/15/2/419 LET TER Distinction between induction and maintenance dosing in continuous renal replacement therapy Graeme MacLaren* See related review by Prowle et al., /content/15/2/207 In their excellent review of dosing continuous renal counter ucrrent ? ow to blood ? ow ratio should be 0.3 replacement therapy (CRRT), Dr Prowle and colleagues with di? usive CRRT, or a ? ltration fraction with concluded that patients should be prescribed 20 to 25 ml/kg/h [1]. However, by averaging CRRT dose over time, studies in this area obfuscate the bene? ts of appro- priately higher dose therapy early in the course of illness, convective therapy 0.2 [2]. As the potassium level falls, the dose can be lowered to more conventional levels. Parallels could be drawn to general anaesthesia, where induction and maintenance are two distinct phases with potentially misguiding clinicians into blindly adopting a di? erent requirements. CRRT prescription could simi lar ly ‘one-size-? ts-all’ approach and consequently prescribing be conceptualized as ‘induction’, where life-threatening inadequate doses in life-threatening emergencies. To take a crude example, it would be inappropriate to prescribe abnor malities are corrected quickly with high-dose therapy, then ‘maintenance’ where solute clearance is achieved with 20 ml/kg/h CRRT in a patient with serum potassium more temperate doses (for example, 20 to 25 ml/kg/h) to 9 mmol/L. Rather, the highest possible dose of CRRT should be initially prescribed to maximize solute avoid complications such as hypo phos phataemia. It seems unlikely that this issue will be the subject of prospective research. Yet the principle that faster correc- clearanc is depends on the maximum circuit ? ow permitted by the access catheter, which in turn deter-