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CVVHDF was started&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The administration and supervision of continuous therapy were carried out by the nurses and physicians of the ICU&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In those patients exhibiting a good course following vasoactive drug withdrawal and with persistent needs for RRT&#44; we switched from continuous to intermittent techniques&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">IHD in our center is carried out by the nurses and physicians of the Department of Nephrology&#44; with daily discussion of the case by both medical teams&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Double-lumen 11&#46;5 RF catheters were inserted in the stable patients programmed for IHD&#44; while double-lumen 13 RF catheters were used in the patients subjected to continuous techniques&#46; These latter catheters were introduced in our Unit in the year 2006&#46; The insertion site was usually the internal jugular vein and femoral vena&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">During the study period we initially used the BSM monitor&#44; followed in the period 2003&#8211;2004 by the Prisma<span class="elsevierStyleSup">&#174;</span> monitor&#44; and since 2005 we have only used the PrismaFlex<span class="elsevierStyleSup">&#174;</span> system for continuous therapy &#40;all from Gambro-Hospal&#41;&#46; The filter used from the time of introduction of the PrismaFlex<span class="elsevierStyleSup">&#174;</span> system has been the M100 filter &#40;AN69&#41; with a biocompatible polyacrylonitrile membrane &#40;0&#46;9<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">During the years of treatment with the Prisma<span class="elsevierStyleSup">&#174;</span> monitor&#44; 20&#8211;25<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h ultrafiltration was performed &#40;the daily dialysis doses are not registered&#41; with arterial pump settings of 150&#8211;180<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#46; After introduction of the PrismaFlex<span class="elsevierStyleSup">&#174;</span> device&#44; ultrafiltration was increased to 35<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h&#44; with arterial pump settings of 280&#8211;330<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In the absence of contraindications&#44; the anticoagulation used during therapy consisted of heparin sodium at a dose of 300&#8211;500<span class="elsevierStyleHsp" style=""></span>IU&#47;h&#44; according to the activated partial thromboplastin time &#40;aPTT&#41; controls&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Data collection</span><p id="par0120" class="elsevierStylePara elsevierViewall">From the time of patient admission&#44; and after confirming compliance with the inclusion criteria&#44; we recorded the following variables on a daily basis&#58; epidemiological parameters &#40;gender&#44; age&#41;&#44; risk factors for renal failure &#40;hypertension&#44; diabetes mellitus&#44; dyslipidemia&#44; postoperative period&#44; associated neoplasm&#41;&#44; APACHE II score&#44; origin of ARF &#40;nosocomial or community acquired&#41;&#44; etiology of ARF &#40;prerenal&#44; renal or obstructive&#41; and urine output &#40;anuria<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>ml&#47;24<span class="elsevierStyleHsp" style=""></span>h&#44; oliguria<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>400<span class="elsevierStyleHsp" style=""></span>ml&#47;24<span class="elsevierStyleHsp" style=""></span>h&#44; and preserved diuresis&#41;&#46; Likewise&#44; we documented the reason for admission to the ICU&#44; the therapy received &#40;intermittent&#44; continuous or both&#41; and the duration of RRT in days&#44; mortality &#40;in the ICU&#41;&#44; and recovery of renal function prior to discharge from the ICU&#46; The complications of RRT were not recorded in the effects of the study&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The recovery of renal function was defined in the descriptive data and in the comparative analysis as full recovery of renal function &#40;normal creatinine concentration at discharge&#41;&#44; or partial recovery of renal function but with no need for IHD &#40;creatinine concentration at discharge<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; or with the need for IHD at discharge from the ICU&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In order to establish the predictors of the recovery of renal function&#44; and in relation to the previously published literature&#44; we divided the patients into only two groups&#58; IHD dependency or non-dependency at discharge from the ICU&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Because of the complexity caused by the variability of the onset of ARF&#44; we were unable to precisely document the start of RRT&#46; Furthermore&#44; the unit protocol does not precisely define the time for introducing such therapy&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Since the publication &#40;in 2004&#41; of the RIFLE score&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> we started to record the latter along with the rest of the data&#44; on a prospective basis&#46; A review was moreover made of the previously entered case histories&#44; conducting a retrospective analysis of the RIFLE score of these patients&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The study interval covers 10 years&#44; divided into two periods&#58; initial &#40;2000&#8211;2004&#41; and recent &#40;2005&#8211;2009&#41;&#46; This division was made with the purpose of comparing the two periods&#44; since it was in the recent period when therapy with high-volume CVVHF was started in our unit&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0150" class="elsevierStylePara elsevierViewall">A descriptive statistical study was made of the study population data&#44; reporting the quantitative variables as the mean and standard deviation&#44; and the categorical variables as percentages&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">After dividing the sample into the two above mentioned periods&#44; a comparative study was made of both periods &#40;initial versus recent&#41;&#44; using the chi-squared test for the qualitative variables&#44; and the Student&#39;s <span class="elsevierStyleItalic">t</span>-test for the quantitative variables&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The results are shown comparing the initial period versus the recent period&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">For the variable therapy provided&#44; we divided the sample into three subgroups&#58; patients receiving only IHD&#59; patients receiving only the continuous modality&#59; and patients receiving both techniques&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The predictors of mortality and of recovery of renal function were established using the Student&#39;s <span class="elsevierStyleItalic">t</span>-test&#44; chi-squared test and Fisher exact test&#46; The survivors were compared versus the patients who died&#44; and on the other hand&#44; comparisons were also made between those patients who upon discharge from the ICU remained dependent on IHD versus those who were not dependent upon IHD&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Multiple logistic regression analysis was made of the variables found to be significant in the univariate analysis &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; as well as of those believed to be significant on the basis of the previously described literature&#8211;with a view to determining possible predictors of the dependent variable under study&#46; The results are reported as the odds ratio &#40;OR&#41; and corresponding 95&#37; confidence interval &#40;95&#37;CI&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Characteristics of the patients&#47;evolutive analysis</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Baseline population characteristics</span><p id="par0180" class="elsevierStylePara elsevierViewall">During the study period&#44; 304 patients with ARF or exacerbated chronic renal failure required RRT&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The demographic data and clinical characteristics of the patients&#44; comparing both periods&#44; are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">The main cause of admission was sepsis&#44; with the respiratory system and abdominal region as the most frequent foci&#46; Risk factors &#40;RFs&#41; for renal failure upon admission were recorded in 85&#46;5&#37; of the patients&#46; Of note in this sense was an increase in arterial hypertension in the recent period&#44; the presence of neoplasms&#44; and an increase in the number of patients with two or more RFs&#46; A community origin of ARF was seen to increase in the recent period&#46; Regarding the RIFLE criteria&#44; at the start of RRT&#44; the most predominant was &#8220;failure&#8221;&#46; ARF was prerenal in 94&#37; of the cases&#8211;the main underlying causes being septic and cardiogenic shock&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Types and duration of renal replacement therapy</span><p id="par0195" class="elsevierStylePara elsevierViewall">One-half of the patients in the study underwent IHD&#44; mainly because the latter is the method used in the unit for weaning from the technique&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Regarding the continuous techniques&#44; CVVHF and high-volume CVVHF were seen to increase significantly on comparing both periods&#44; with a decrease in CVVHDF&#46; Up to 75&#37; of the patients used continuous techniques &#40;alone or combined with IHD&#41;&#44; and an increase was recorded in the number of patients combining more than one continuous technique &#40;16&#46;7&#37; versus 26&#46;4&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Regarding the days of treatment&#44; a significant decrease was observed in the recent period on summing all the techniques received by the patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Mortality and recovery of renal function</span><p id="par0210" class="elsevierStylePara elsevierViewall">The global mortality rate in the study cohort was 52&#46;3&#37;&#8211;the main cause of death being MODS&#44; with the observation of a significant decrease between the two periods &#40;61&#46;9&#37; versus 45&#46;5&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall">Referred to the survivors &#40;145 patients&#41; at discharge from the ICU&#44; we recorded a decrease over time in the resolution of renal failure&#44; an increase in the number of patients dependent upon IHD&#44; and a stable number of chronic cases with no need for IHD &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Predictors of mortality and renal recovery</span><p id="par0220" class="elsevierStylePara elsevierViewall">In the 10 years of the study&#44; a total of 159 of the 304 patients died &#40;52&#46;3&#37;&#41;&#46; The variables found to be significant predictors of mortality in the univariate analysis were creatinine upon admission and creatinine at the start of the technique&#8211;both being higher among the survivors&#46; Likewise&#44; the origin of renal failure was identified as a significant variable&#59; specifically&#44; patients with ARF originating in hospital suffered greater mortality than those with community-acquired ARF &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0225" class="elsevierStylePara elsevierViewall">Septic shock as a cause of ARF also proved significant in the univariate analysis &#40;57&#46;9&#37; versus 44&#46;4&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;014&#41;&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Another factor adding to mortality was the renal replacement technique used&#46; In effect&#44; the mortality rate was higher among the patients subjected to continuous techniques versus only the intermittent mode or those patients subjected to both treatment modes&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">In the multivariate analysis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; and after adjusting for age and the APACHE II score upon admission&#44; the variables independently related to mortality were the following&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0240" class="elsevierStylePara elsevierViewall">Creatinine upon admission &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#59; OR 0&#46;77&#59; 95&#37;CI 0&#46;61&#8211;0&#46;97&#41;&#46; The survivors showed greater creatinine upon admission&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0245" class="elsevierStylePara elsevierViewall">The replacement therapy received&#46; Specifically&#44; intermittent treatment was a predictor of mortality versus those subjected to continuous therapy or both techniques &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;015&#59; OR 0&#46;37&#59; 95&#37;CI 0&#46;16&#8211;0&#46;87&#41;&#46;</p></li></ul></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0250" class="elsevierStylePara elsevierViewall">Regarding the recovery of renal function among the survivors &#40;145 patients&#41;&#44; only 21&#46;4&#37; of the total patients &#40;31 subjects&#41; required IHD at discharge&#46; After excluding the patients &#40;34 subjects&#41; who already presented previous known renal failure &#40;creatinine<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; from the group of survivors&#44; the percentage of patients requiring IHD at discharge decreased to 11&#37;&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">The variables identified by the univariate analysis as being significantly associated to the need for IHD at discharge were creatinine upon admission&#44; creatinine at the start of the technique&#44; and patients with previous chronic renal failure&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">The variables significantly associated to the recovery of renal function were septic shock as the origin of ARF and the replacement therapy received&#46; Specifically&#44; the subjects who received continuous treatment required IHD at discharge less often than those who received both techniques &#40;7&#46;1&#37; versus 26&#46;5&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#46; There were no significant differences between the continuous and intermittent techniques &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0265" class="elsevierStylePara elsevierViewall">In the multivariate logistic regression analysis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; the variables shown to be independently related to the need for IHD at discharge from the ICU were the following&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0270" class="elsevierStylePara elsevierViewall">Creatinine upon admission &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#59; OR 1&#46;98&#59; 95&#37;CI 1&#46;12&#8211;3&#46;48&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0275" class="elsevierStylePara elsevierViewall">The type of renal failure&#58; acute versus exacerbated chronic failure &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#59; OR 0&#46;11&#59; 95&#37;CI 0&#46;04&#8211;0&#46;34&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0280" class="elsevierStylePara elsevierViewall">The continuous technique as treatment received versus the group subjected to both techniques &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#59; OR 0&#46;18&#59; 95&#37;CI 0&#46;03&#8211;0&#46;85&#41;&#46;</p></li></ul></p></span></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0285" class="elsevierStylePara elsevierViewall">The present study shows that the survival of critical patients requiring RRT due to renal failure has improved over time&#46; All the patients were treated according to the homogeneous protocol used in our Unit&#44; with variability being limited to changes in the therapy provided in accordance with the literature published during these years and the improvements in the global treatments provided in our Unit&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">Although the global mortality of our patients has been similar to that described in the literature&#44; the main finding in our study was the decrease in mortality observed despite the fact that these are older patents&#44; with increased comorbidity and in very serious condition &#40;APACHE II<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>20&#41;&#46; These findings are in contrast to the published data affirming that mortality in patients with ARF remains high despite the medical advances&#44; because of the greater age of the patients&#44; greater comorbidity&#44; and a more serious patient condition&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0295" class="elsevierStylePara elsevierViewall">While old&#44; several publications offer results similar to our own&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> Turney et al<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> compared patients with ARF &#40;admitted or not to the ICU&#41; treated in two different time periods&#44; and reported a decrease in mortality rate from 51&#37; to 42&#37;&#44; despite an increase in age and in the seriousness of the patient condition&#46; Bisenbach et al<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> in turn compared three consecutive time periods and likewise found a progressive drop in mortality rate from 69&#37; to 54&#37; and 48&#37;&#44; despite an increase in patient age&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">In addition to the decrease in mortality&#44; we recorded a significant reduction in the days of therapy between the two time periods&#46; In our case&#44; considering similar characteristics in both groups and knowing that most patients presented ARF secondary to septic shock&#44; we attributed the decrease in mortality and in days of therapy to implementation of the treatment recommendations established from publication of the sepsis management guides&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">This is justified by the greater number of cases of ARF originating in the community during the second time period&#44; which would correspond to the septic patients admitted during that period&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">Of note is the observation that despite the decrease in days of therapy and in mortality&#44; the number of patients dependent upon IHD at discharge was higher in the recent period&#46; This is probably related to the larger number of patients with exacerbated chronic renal failure&#44; older age and a greater number of RFs for the development of renal failure&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Although this may be incongruent&#44; fewer days of therapy but more patients requiring IHD at discharge could be explained by the small number of patients needing RRT at discharge from the ICU&#44; together with the fact that many of these patients will not require IHD prior to hospital discharge&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">These conclusions are complex and may be due to the difficult and scant definition of the concepts of ARF and exacerbated chronic renal failure&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">Regarding the applied technique&#44; it is well known that the article published by Ronco et al&#46; in the year 2000<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> led to important changes in the management of our patients&#44; with the incorporation of an increased use of convection&#44; and a decrease in diffusion&#46; Furthermore&#44; the Acute Dialysis Quality Initiative&#44; on occasion of its third consensus conference&#44; recommended a dose of 35<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h in septic patients &#40;evidence level II and degree of recommendation C&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0330" class="elsevierStylePara elsevierViewall">This caused many Units to replace their RRT machines with systems characterized by higher ultrafiltration flows&#44; and consequently involving higher pressures&#44; and to the great increase in the utilization of convective therapy&#46; A decade later&#44; in 2008 and 2009&#44;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> two studies have been published where despite the limitations involved&#44; the efficacy and safety of the treatment applied in recent years has been questioned&#44; and even new concepts have emerged such as &#8220;dialytrauma&#8221;&#8211;causing us to reflect upon and analyze how the high dialysis doses affect our patients and the rest of their treatment &#40;antibiotics&#44; nutrition&#44; etc&#46;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> At present&#44; this has led us to assess the dialysis dose requirements of our patients on a daily basis&#44; introducing changes according to their evolution over time&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">On analyzing the mortality predictors in our study population&#44; one of the variables correlated to increased mortality was creatinine upon admission&#8211;with higher values among the survivors&#46; Since most of the patients were septic cases&#44; we probably could deduce that since these subjects had higher creatinine levels&#44; they were placed on dialysis earlier &#40;though in our work&#44; and as a limiting element of the study&#44; the RRT starting time was not documented&#41;&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">Recently&#44; however&#44; Chou et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> have published a propensity score analysis of the relationship between the RIFLE criteria<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and the early or late start of replacement therapy&#46; The authors conclude that the mentioned classification is a poor predictor of the benefits of early or late initiation of RRT in the septic patient&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">The other important finding in our study was that the therapy provided is independently associated with increased mortality&#8211;the provision of intermittent therapy only being a protective factor against mortality compared with continuous treatment or a combination of both techniques &#40;OR 0&#46;77&#41;&#46; Ours is an observational study&#59; this result therefore cannot be inferred from the logistic regression analysis&#46; Despite adjustment for the APACHE II score and age&#44; there are very important limitations&#59; given the protocol used in our Unit&#44; it was obvious that those patients who were only subjected to intermittent treatment&#44; as less seriously ill individuals&#44; also suffered lesser mortality&#46;</p><p id="par0350" class="elsevierStylePara elsevierViewall">Regarding the predictors of the recovery of renal function at discharge from the ICU&#44; our findings are not very different from those published to date&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5&#44;7</span></a> At discharge from the ICU&#44; only 21&#46;4&#37; of the patients required IHD&#44; and if from these we exclude the chronic cases &#40;basal creatinine<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#44; then the percentage drops to 11&#37;&#46;</p><p id="par0355" class="elsevierStylePara elsevierViewall">In our case&#44; elevated creatinine values upon admission represented a risk factor for dependency upon IHD at discharge &#40;OR 1&#46;98&#41;&#46; On the other hand&#44; ARF versus exacerbated chronic renal failure was identified as a protective factor&#44; in the same way as continuous techniques as RRT versus the group of patients receiving both treatment modes&#46;</p><p id="par0360" class="elsevierStylePara elsevierViewall">Another important limitation appears here&#44; since the group of survivors did not include the patients who died&#44; and the great majority of those who died did so while receiving treatment with continuous techniques&#46; The patients only subjected to continuous treatment and which improved were therefore more likely to recover better renal function than the patients who were previously on IHD&#46; Here again&#44; however&#44; we cannot infer that the continuous techniques are related to improved recovery of renal function&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">Our study has a number of important limitations&#46; A first limitation is the complexity of the variables and of the definitions involved&#8211;a situation still in wait of improvement after all these years of research in the field of renal failure&#46; On the other hand&#44; the time of the start of RRT has not been registered&#44; and no analysis has been made of the evolution of the SOFA score of the patient in the ICU&#44; or of other severity scores at the time of initiation of RRT&#46; As a result&#44; no extrapolation can be made to the APACHE II score of the same patient 24<span class="elsevierStyleHsp" style=""></span>h after admission to the ICU&#46;</p><p id="par0370" class="elsevierStylePara elsevierViewall">Despite the results of the regression analysis&#44; we cannot independently relate the different techniques to patient mortality and&#47;or the recovery of renal function&#44; since this is an observational study&#44; and the protocol used in our Unit precludes such inference&#46;</p><p id="par0375" class="elsevierStylePara elsevierViewall">Lastly&#44; another important limitation is the fact that no registry has been made of the complications of RRT&#44; for although such complications are well defined and are few&#44; they could also have been analyzed according to the technique used&#46;</p><p id="par0380" class="elsevierStylePara elsevierViewall">In conclusion&#44; critical patients requiring RRT have shown lower mortality rates in recent years&#44; and require fewer days of therapy&#46; This situation is probably attributable to improvements in the global management of these patients&#44; since many other factors in addition to RRT influence patient outcome&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0385" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => array:8 [
            0 => "Abstract"
            1 => "Objectives"
            2 => "Design"
            3 => "Setting"
            4 => "Patients"
            5 => "Primary variables of interest"
            6 => "Results"
            7 => "Conclusions"
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          "identificador" => "xpalclavsec10451"
          "titulo" => "Keywords"
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        2 => array:2 [
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          "titulo" => array:8 [
            0 => "Resumen"
            1 => "Objetivos"
            2 => "Dise&#241;o"
            3 => "&#193;mbito"
            4 => "Pacientes"
            5 => "Principales variables de inter&#233;s"
            6 => "Resultados"
            7 => "Conclusiones"
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        ]
        3 => array:2 [
          "identificador" => "xpalclavsec10452"
          "titulo" => "Palabras clave"
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        4 => array:2 [
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          "titulo" => "Introduction"
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        5 => array:3 [
          "identificador" => "sec0010"
          "titulo" => "Patients and methods"
          "secciones" => array:4 [
            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Study population and period"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Renal replacement therapy"
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            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Data collection"
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            3 => array:2 [
              "identificador" => "sec0030"
              "titulo" => "Statistical analysis"
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          "titulo" => "Results"
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            0 => array:3 [
              "identificador" => "sec0040"
              "titulo" => "Characteristics of the patients&#47;evolutive analysis"
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                0 => array:2 [
                  "identificador" => "sec0045"
                  "titulo" => "Baseline population characteristics"
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                1 => array:2 [
                  "identificador" => "sec0050"
                  "titulo" => "Types and duration of renal replacement therapy"
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                2 => array:2 [
                  "identificador" => "sec0055"
                  "titulo" => "Mortality and recovery of renal function"
                ]
                3 => array:2 [
                  "identificador" => "sec0060"
                  "titulo" => "Predictors of mortality and renal recovery"
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              ]
            ]
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          "identificador" => "sec0065"
          "titulo" => "Discussion"
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        8 => array:2 [
          "identificador" => "sec0070"
          "titulo" => "Conflicts of interest"
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        9 => array:1 [
          "titulo" => "References"
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    "pdfFichero" => "main.pdf"
    "tienePdf" => true
    "fechaRecibido" => "2011-08-01"
    "fechaAceptado" => "2012-01-14"
    "PalabrasClave" => array:2 [
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        0 => array:4 [
          "clase" => "keyword"
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          "palabras" => array:4 [
            0 => "Renal replacement therapy"
            1 => "Intermittent hemodialysis"
            2 => "Hemofiltration"
            3 => "Septic shock"
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      "es" => array:1 [
        0 => array:4 [
          "clase" => "keyword"
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          "identificador" => "xpalclavsec10452"
          "palabras" => array:4 [
            0 => "Tratamiento de reemplazo renal"
            1 => "Hemodialisis intermitente"
            2 => "Hemofiltraci&#243;n"
            3 => "Shock s&#233;ptico"
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      "en" => array:2 [
        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To analyze the evolution of patients subjected to renal replacement therapy &#40;RRT&#41;&#44; and to determine risk factors associated with mortality and the recovery of renal function&#46;</p> <span class="elsevierStyleSectionTitle">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective&#44; observational study of critically-ill patients&#46;</p> <span class="elsevierStyleSectionTitle">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Clinical&#8211;surgical Intensive Care Unit &#40;ICU&#41; of Sabadell Hospital &#40;Spain&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Patients</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Inclusion of all patients treated in our unit due to acute renal failure &#40;ARF&#41; requiring RRT&#46;</p> <span class="elsevierStyleSectionTitle">Primary variables of interest</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">We recorded epidemiological data&#44; severity using the APACHE II score&#44; days of the technique&#44; ICU mortality&#44; and renal function recovery&#46; The study period was divided into 2 parts&#58; part 1 &#40;2000&#8211;2004&#41; and part 2 &#40;2005&#8211;2009&#41;&#46; The 2 periods were compared using the Student&#39;s <span class="elsevierStyleItalic">t</span>-test for continuous variables and the chi-squared test for categorical variables&#46; Multiple regression analysis was performed to determine the risk factors for mortality and recovery of renal function&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A total of 304 patients were treated&#46; Sepsis was the main etiology of ARF &#40;61&#37;&#41;&#44; involving principally respiratory and abdominal foci&#46; In the second period the convective technique and community-acquired ARF were far more prevalent than in the first period&#46; There were fewer days of therapy in the second period &#40;19&#46;7 versus 12&#46;3 days&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;015&#41;&#46; Total ICU mortality was 52&#46;3&#37;&#44; with a decrease in the last period &#40;61&#46;9&#8211;45&#46;5&#37;&#58; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;003&#41;&#46; The risk factors associated with mortality were creatinine upon admission &#40;odds ratio &#91;OR&#93; 0&#46;77&#59; 95&#37; confidence interval &#91;95&#37;CI&#93; 0&#46;61&#8211;0&#46;97&#41; and treatment with IHD alone &#40;OR 0&#46;37&#44; 95&#37;CI 0&#46;16&#8211;0&#46;87&#41;&#46; Survivors had normal renal function at ICU discharge in 56&#46;7&#37; of the cases in the second period&#44; vs in 72&#46;9&#37; in the first period&#44; with more patients subjected to IHD in the second period &#40;10&#46;4&#37; versus 26&#46;8&#37;&#41;&#46; The factors related to the recovery of renal function were creatinine upon admission &#40;OR 1&#46;98&#44; 95&#37;CI 1&#46;12&#8211;3&#46;48&#41;&#44; acute renal failure &#40;OR 0&#46;11&#44; 95&#37;CI 0&#46;04&#8211;0&#46;34&#41; and treatment with continuous techniques &#40;OR 0&#46;18&#44; 95&#37;CI 0&#46;03&#8211;0&#46;85&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Mortality among critically-ill patients subjected to RRT has improved in recent years&#46;</p>"
      ]
      "es" => array:2 [
        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivos</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Analizar la evoluci&#243;n de los pacientes con insuficiencia renal aguda tratados con terapia de reemplazo renal &#40;TRR&#41; y determinar los factores de riesgo asociados a mortalidad y recuperaci&#243;n de la funci&#243;n renal&#46;</p> <span class="elsevierStyleSectionTitle">Dise&#241;o</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo y observacional en pacientes cr&#237;ticos&#46;</p> <span class="elsevierStyleSectionTitle">&#193;mbito</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Unidad de Cuidados Intensivos &#40;UCI&#41; polivalente del Hospital de Sabadell&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Inclusi&#243;n de los pacientes con insuficiencia renal que precisaron TRR en nuestra unidad&#46;</p> <span class="elsevierStyleSectionTitle">Principales variables de inter&#233;s</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Registro de variables epidemiol&#243;gicas&#44; de gravedad &#40;APACHE II&#41; as&#237; como el tipo y duraci&#243;n de la TRR&#44; mortalidad y recuperaci&#243;n de la funci&#243;n renal al alta de UCI&#46; El periodo de estudio comprende 10 a&#241;os&#44; repartiendo la muestra en 2 periodos&#58; inicial &#40;2000-2004&#41; y reciente &#40;2005-2009&#41;&#46; An&#225;lisis estad&#237;stico comparativo de ambos periodos y an&#225;lisis de regresi&#243;n log&#237;stica m&#250;ltiple para determinar factores de riesgo de mortalidad y de recuperaci&#243;n de funci&#243;n renal&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis de 304 pacientes&#46; Principal causa de ingreso la sepsis &#40;61&#37;&#41;&#44; siendo el foco respiratorio y el abdominal los m&#225;s frecuentes&#46; El origen comunitario de la insuficiencia renal y la t&#233;cnica convectiva se incrementaron en el periodo reciente&#46; Destaca un descenso de d&#237;as de terapia &#40;19&#44;7 a 12&#44;3&#59; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span>0&#44;015&#41;&#46; La mortalidad global en UCI fue de 52&#44;3&#37;&#44; siendo la principal causa el fallo multiorg&#225;nico&#44; objetivando un descenso entre ambos periodos &#40;61&#44;9 a 45&#44;5&#37;&#59; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span>0&#44;003&#41;&#46; Los factores relacionados con la mortalidad fueron la creatinina al ingreso &#40;<span class="elsevierStyleItalic">odds ratio</span> &#91;OR&#93; 0&#44;77&#59; intervalo de confianza del 95&#37; &#91;IC95&#37;&#93; 0&#44;61-0&#44;97&#41; y el tratamiento solo con HDI &#40;OR 0&#44;37&#59; IC95&#37; 0&#44;16-0&#44;87&#41;&#46; De los supervivientes&#44; al alta de UCI&#44; en el periodo reciente destaca un aumento de los pacientes que quedan con dependencia de HD &#40;10&#44;4 versus 26&#44;8&#37;&#41;&#46; Los factores relacionados con la recuperaci&#243;n de la funci&#243;n renal fueron la creatinina al ingreso &#40;OR 1&#44;98&#59; IC95&#37; 1&#44;12-3&#44;48&#41;&#44; la insuficiencia renal aguda versus la cr&#243;nica agudizada &#40;OR 0&#44;11&#59; IC95&#37; 0&#44;04-0&#44;34&#41; y el tratamiento con t&#233;cnicas continuas &#40;OR 0&#44;18&#59; IC95&#37; 0&#44;03-0&#44;85&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">La mortalidad de los pacientes cr&#237;ticos tratados con TRR ha mejorado en los &#250;ltimos a&#241;os&#46;</p>"
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        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Navas A&#44; et al&#46; Terapia de reemplazo renal en paciente cr&#237;tico&#58; cambios evolutivos del tratamiento en los &#250;ltimos a&#241;os&#46; Med Intensiva&#46; 2012&#59;36&#58;540&#8211;7&#46;</p>"
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Evolution of the recovery of renal function in the survivors &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>145&#41;&#46; Healing&#58; full recovery&#59; chronic&#58; partial recovery &#40;creatinine<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#59; Chronic HD&#58; need for IHD at discharge from the ICU &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;06&#41;&#46; IP&#58; initial period&#59; RP&#58; recent period&#46;</p>"
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                  """
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                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Anuria &#40;&#60;100<span class="elsevierStyleHsp" style=""></span>ml&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Oliguria &#40;&#60;400<span class="elsevierStyleHsp" style=""></span>ml&#47;24<span class="elsevierStyleHsp" style=""></span>h&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Preserved diuresis&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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Renal replacement therapy in the critical patient: Treatment variation over time
Terapia de reemplazo renal en paciente crítico: cambios evolutivos del tratamiento en los últimos años
A. Navasa,
Corresponding author
anavas@tauli.cat

Corresponding author.
, R. Ferrerb, M. Martíneza, M.L. Martíneza, C. de Haroa, A. Artigasa
a Centre de Crítics, Hospital de Sabadell, Corporació Sanitària i Universitària Parc Taulí (CSIUPT), Universitat Autònoma de Barcelona, Sabadell, CIBER Enfermedades Respiratorias, Spain
b Servei de Medicina Intensiva, Hospital Universitari Mútua de Terrassa, Universitat de Barcelona, Terrassa, CIBER Enfermedades Respiratorias, Spain
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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">The different studies conducted to date reveal high incidences of acute renal failure &#40;ARF&#41; in hospitalized patients&#44; and particularly among critically-ill patients&#46;<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Moreover&#44; since ARF in the critical patient is associated with multiorgan dysfunction syndrome &#40;MODS&#41;&#44; the mortality rate among such individuals is much higher &#40;35&#8211;53&#37; depending on the source&#41; than in patients without ARF admitted to the Intensive Care Unit &#40;ICU&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0010"><span class="elsevierStyleSup">2&#44;3</span></a> Even the need for renal replacement therapy &#40;RRT&#41; in the critical patient has been shown to be an independent predictor of mortality&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">In recent years there have been many changes in RRT which in turn have led to important improvements&#46; 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given the current characteristics of the patients&#44; the needs for intermittent hemodialysis &#40;IHD&#41; at discharge have increased&#46;<a class="elsevierStyleCrossRefs" href="#bib0035"><span class="elsevierStyleSup">7&#8211;9</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Among those patients who survive&#44; most will recover from failure with good quality of life at discharge&#44; while 5&#8211;20&#37; will require IHD after leaving hospital&#46;<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">The primary objective of this study was to describe the characteristics of the patients admitted to the ICU with ARF and who required RRT&#44; and to analyze the evolutive changes of the patients and of the treatment received over the years&#46; The secondary objective was to identify the risk factors associated to mortality and the recovery of renal function in the study cohort&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Patients and methods</span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Study population and period</span><p id="par0030" class="elsevierStylePara elsevierViewall">We prospectively included all the patients admitted to our Unit with ARF or exacerbated chronic renal failure &#40;previous creatinine<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; requiring RRT &#40;both intermittent and continuous&#41; during their stay in Intensive Care&#46;</p><p id="par0035" class="elsevierStylePara elsevierViewall">We only excluded those patients with chronic renal failure who were already enrolled in a previous IHD program&#46; Ours is a polyvalent Unit with 26 beds &#40;16 in the ICU plus 10 in Semicritical Care&#41; that receives clinical&#44; postsurgical and trauma cases&#46; Given the logistics of our Unit&#44; and depending on the nursing activity burden&#44; we can perform IHD and continuous renal replacement techniques &#40;CRRTs&#41; in all 16 boxes of the ICU&#46; In the Semicritical Care area we can only perform IHD &#40;supervised by Nephrology nursing personnel&#41; in one of the boxes&#59; alternatively&#44; the patients are moved to the acute patients area of Nephrology for IHD&#46; Patients on IHD while in the Semicritical Care area and who suffer clinical worsening with the need to switch to CRRT are moved to the ICU&#46;</p><p id="par0040" class="elsevierStylePara elsevierViewall">Acute renal failure was defined as a creatinine increase to &#62;2<span class="elsevierStyleHsp" style=""></span>mg&#47;dl &#40;if previously normal&#41;&#44; with urea 150&#8211;200<span class="elsevierStyleHsp" style=""></span>mg&#47;dl and preserved diuresis&#44; oliguria or anuria &#40;at the time of data collection referred to these patients&#44; the RIFLE criteria had not yet been defined&#41;&#46;</p><p id="par0045" class="elsevierStylePara elsevierViewall">Exacerbated chronic renal failure in turn was diagnosed in those patients with worsening of basal creatinine at the time of admission&#44; with a concentration of &#62;1&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#46; This parameter was checked from previous admissions of the patients or on the basis of their antecedents&#46; Creatinine clearance of the patients was not registered&#46;</p><p id="par0050" class="elsevierStylePara elsevierViewall">In a very low percentage of patients&#44; and due to the absence of prior data or reports&#44; the basal creatinine was not known&#46;</p><p id="par0055" class="elsevierStylePara elsevierViewall">Critical patients of septic origin were treated according to the guidelines of the Surviving Sepsis Campaign<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a> from the time when they were published in 2004&#46;</p><p id="par0060" class="elsevierStylePara elsevierViewall">The inclusion period of the study extended from January 2000 to December 2009&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Renal replacement therapy</span><p id="par0065" class="elsevierStylePara elsevierViewall">The indications of RRT were hypervolemia with respiratory involvement refractory to diuretic treatment&#44; uremia 150&#8211;200<span class="elsevierStyleHsp" style=""></span>mg&#47;dl with clinical involvement&#44; hyperpotassemia&#44; pericarditis and&#47;or uremic encephalopathy and severe metabolic acidosis &#40;pH<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>7&#41;&#46;</p><p id="par0070" class="elsevierStylePara elsevierViewall">In recent years&#44; and on the basis of the published literature&#44; RRT &#40;particularly in continuous mode&#41; was indicated both based on the previously defined classical criteria and in the context of ARF with multiorgan failure secondary to septic shock&#46; No septic shock patients without ARF were treated&#46;</p><p id="par0075" class="elsevierStylePara elsevierViewall">The type of RRT &#40;IHD&#44; continuous venous&#8211;venous hemofiltration &#40;CVVHF&#41;&#44; continuous venous&#8211;venous hemodiafiltration &#40;CVVHDF&#41;&#44; high-volume continuous venous&#8211;venous hemofiltration&#41; was decided according to medical criterion&#44; following a homogeneous protocol used in the unit&#46;</p><p id="par0080" class="elsevierStylePara elsevierViewall">According to the mentioned protocol&#44; continuous therapy was provided in all patients with hemodynamic instability &#40;requiring vasoactive drugs&#41; and in those subjects presenting intolerance &#40;hypotension with systolic blood pressure &#40;SBP&#41;<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>90<span class="elsevierStyleHsp" style=""></span>mmHg&#41; to the intermittent technique&#46; As per protocol&#44; the continuous technique was always started in septic patients in the form of CVVHF&#44; and starting in 2006 with the switch to PrismaFlex<span class="elsevierStyleSup">&#174;</span>&#44; it was started in the form of high-volume CVVHF &#40;35<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h&#41;&#46; In patients with obesity&#44; severe catabolism&#44; or hyperpotassemia with clinical involvement&#44; CVVHDF was started&#46;</p><p id="par0085" class="elsevierStylePara elsevierViewall">The administration and supervision of continuous therapy were carried out by the nurses and physicians of the ICU&#46;</p><p id="par0090" class="elsevierStylePara elsevierViewall">In those patients exhibiting a good course following vasoactive drug withdrawal and with persistent needs for RRT&#44; we switched from continuous to intermittent techniques&#46;</p><p id="par0095" class="elsevierStylePara elsevierViewall">IHD in our center is carried out by the nurses and physicians of the Department of Nephrology&#44; with daily discussion of the case by both medical teams&#46;</p><p id="par0100" class="elsevierStylePara elsevierViewall">Double-lumen 11&#46;5 RF catheters were inserted in the stable patients programmed for IHD&#44; while double-lumen 13 RF catheters were used in the patients subjected to continuous techniques&#46; These latter catheters were introduced in our Unit in the year 2006&#46; The insertion site was usually the internal jugular vein and femoral vena&#46;</p><p id="par0105" class="elsevierStylePara elsevierViewall">During the study period we initially used the BSM monitor&#44; followed in the period 2003&#8211;2004 by the Prisma<span class="elsevierStyleSup">&#174;</span> monitor&#44; and since 2005 we have only used the PrismaFlex<span class="elsevierStyleSup">&#174;</span> system for continuous therapy &#40;all from Gambro-Hospal&#41;&#46; The filter used from the time of introduction of the PrismaFlex<span class="elsevierStyleSup">&#174;</span> system has been the M100 filter &#40;AN69&#41; with a biocompatible polyacrylonitrile membrane &#40;0&#46;9<span class="elsevierStyleHsp" style=""></span>m<span class="elsevierStyleSup">2</span>&#41;&#46;</p><p id="par0110" class="elsevierStylePara elsevierViewall">During the years of treatment with the Prisma<span class="elsevierStyleSup">&#174;</span> monitor&#44; 20&#8211;25<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h ultrafiltration was performed &#40;the daily dialysis doses are not registered&#41; with arterial pump settings of 150&#8211;180<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#46; After introduction of the PrismaFlex<span class="elsevierStyleSup">&#174;</span> device&#44; ultrafiltration was increased to 35<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h&#44; with arterial pump settings of 280&#8211;330<span class="elsevierStyleHsp" style=""></span>ml&#47;min&#46;</p><p id="par0115" class="elsevierStylePara elsevierViewall">In the absence of contraindications&#44; the anticoagulation used during therapy consisted of heparin sodium at a dose of 300&#8211;500<span class="elsevierStyleHsp" style=""></span>IU&#47;h&#44; according to the activated partial thromboplastin time &#40;aPTT&#41; controls&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Data collection</span><p id="par0120" class="elsevierStylePara elsevierViewall">From the time of patient admission&#44; and after confirming compliance with the inclusion criteria&#44; we recorded the following variables on a daily basis&#58; epidemiological parameters &#40;gender&#44; age&#41;&#44; risk factors for renal failure &#40;hypertension&#44; diabetes mellitus&#44; dyslipidemia&#44; postoperative period&#44; associated neoplasm&#41;&#44; APACHE II score&#44; origin of ARF &#40;nosocomial or community acquired&#41;&#44; etiology of ARF &#40;prerenal&#44; renal or obstructive&#41; and urine output &#40;anuria<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>100<span class="elsevierStyleHsp" style=""></span>ml&#47;24<span class="elsevierStyleHsp" style=""></span>h&#44; oliguria<span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>400<span class="elsevierStyleHsp" style=""></span>ml&#47;24<span class="elsevierStyleHsp" style=""></span>h&#44; and preserved diuresis&#41;&#46; Likewise&#44; we documented the reason for admission to the ICU&#44; the therapy received &#40;intermittent&#44; continuous or both&#41; and the duration of RRT in days&#44; mortality &#40;in the ICU&#41;&#44; and recovery of renal function prior to discharge from the ICU&#46; The complications of RRT were not recorded in the effects of the study&#46;</p><p id="par0125" class="elsevierStylePara elsevierViewall">The recovery of renal function was defined in the descriptive data and in the comparative analysis as full recovery of renal function &#40;normal creatinine concentration at discharge&#41;&#44; or partial recovery of renal function but with no need for IHD &#40;creatinine concentration at discharge<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; or with the need for IHD at discharge from the ICU&#46;</p><p id="par0130" class="elsevierStylePara elsevierViewall">In order to establish the predictors of the recovery of renal function&#44; and in relation to the previously published literature&#44; we divided the patients into only two groups&#58; IHD dependency or non-dependency at discharge from the ICU&#46;</p><p id="par0135" class="elsevierStylePara elsevierViewall">Because of the complexity caused by the variability of the onset of ARF&#44; we were unable to precisely document the start of RRT&#46; Furthermore&#44; the unit protocol does not precisely define the time for introducing such therapy&#46;</p><p id="par0140" class="elsevierStylePara elsevierViewall">Since the publication &#40;in 2004&#41; of the RIFLE score&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> we started to record the latter along with the rest of the data&#44; on a prospective basis&#46; A review was moreover made of the previously entered case histories&#44; conducting a retrospective analysis of the RIFLE score of these patients&#46;</p><p id="par0145" class="elsevierStylePara elsevierViewall">The study interval covers 10 years&#44; divided into two periods&#58; initial &#40;2000&#8211;2004&#41; and recent &#40;2005&#8211;2009&#41;&#46; This division was made with the purpose of comparing the two periods&#44; since it was in the recent period when therapy with high-volume CVVHF was started in our unit&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Statistical analysis</span><p id="par0150" class="elsevierStylePara elsevierViewall">A descriptive statistical study was made of the study population data&#44; reporting the quantitative variables as the mean and standard deviation&#44; and the categorical variables as percentages&#46;</p><p id="par0155" class="elsevierStylePara elsevierViewall">After dividing the sample into the two above mentioned periods&#44; a comparative study was made of both periods &#40;initial versus recent&#41;&#44; using the chi-squared test for the qualitative variables&#44; and the Student&#39;s <span class="elsevierStyleItalic">t</span>-test for the quantitative variables&#46;</p><p id="par0160" class="elsevierStylePara elsevierViewall">The results are shown comparing the initial period versus the recent period&#46;</p><p id="par0165" class="elsevierStylePara elsevierViewall">For the variable therapy provided&#44; we divided the sample into three subgroups&#58; patients receiving only IHD&#59; patients receiving only the continuous modality&#59; and patients receiving both techniques&#46;</p><p id="par0170" class="elsevierStylePara elsevierViewall">The predictors of mortality and of recovery of renal function were established using the Student&#39;s <span class="elsevierStyleItalic">t</span>-test&#44; chi-squared test and Fisher exact test&#46; The survivors were compared versus the patients who died&#44; and on the other hand&#44; comparisons were also made between those patients who upon discharge from the ICU remained dependent on IHD versus those who were not dependent upon IHD&#46;</p><p id="par0175" class="elsevierStylePara elsevierViewall">Multiple logistic regression analysis was made of the variables found to be significant in the univariate analysis &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;05&#41;&#44; as well as of those believed to be significant on the basis of the previously described literature&#8211;with a view to determining possible predictors of the dependent variable under study&#46; The results are reported as the odds ratio &#40;OR&#41; and corresponding 95&#37; confidence interval &#40;95&#37;CI&#41;&#46;</p></span></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Results</span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Characteristics of the patients&#47;evolutive analysis</span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Baseline population characteristics</span><p id="par0180" class="elsevierStylePara elsevierViewall">During the study period&#44; 304 patients with ARF or exacerbated chronic renal failure required RRT&#46;</p><p id="par0185" class="elsevierStylePara elsevierViewall">The demographic data and clinical characteristics of the patients&#44; comparing both periods&#44; are shown in <a class="elsevierStyleCrossRef" href="#tbl0005">Table 1</a>&#46;</p><elsevierMultimedia ident="tbl0005"></elsevierMultimedia><p id="par0190" class="elsevierStylePara elsevierViewall">The main cause of admission was sepsis&#44; with the respiratory system and abdominal region as the most frequent foci&#46; Risk factors &#40;RFs&#41; for renal failure upon admission were recorded in 85&#46;5&#37; of the patients&#46; Of note in this sense was an increase in arterial hypertension in the recent period&#44; the presence of neoplasms&#44; and an increase in the number of patients with two or more RFs&#46; A community origin of ARF was seen to increase in the recent period&#46; Regarding the RIFLE criteria&#44; at the start of RRT&#44; the most predominant was &#8220;failure&#8221;&#46; ARF was prerenal in 94&#37; of the cases&#8211;the main underlying causes being septic and cardiogenic shock&#46;</p></span><span id="sec0050" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Types and duration of renal replacement therapy</span><p id="par0195" class="elsevierStylePara elsevierViewall">One-half of the patients in the study underwent IHD&#44; mainly because the latter is the method used in the unit for weaning from the technique&#46;</p><p id="par0200" class="elsevierStylePara elsevierViewall">Regarding the continuous techniques&#44; CVVHF and high-volume CVVHF were seen to increase significantly on comparing both periods&#44; with a decrease in CVVHDF&#46; Up to 75&#37; of the patients used continuous techniques &#40;alone or combined with IHD&#41;&#44; and an increase was recorded in the number of patients combining more than one continuous technique &#40;16&#46;7&#37; versus 26&#46;4&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#41;&#46;</p><p id="par0205" class="elsevierStylePara elsevierViewall">Regarding the days of treatment&#44; a significant decrease was observed in the recent period on summing all the techniques received by the patients &#40;<a class="elsevierStyleCrossRef" href="#tbl0010">Table 2</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0010"></elsevierMultimedia></span><span id="sec0055" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Mortality and recovery of renal function</span><p id="par0210" class="elsevierStylePara elsevierViewall">The global mortality rate in the study cohort was 52&#46;3&#37;&#8211;the main cause of death being MODS&#44; with the observation of a significant decrease between the two periods &#40;61&#46;9&#37; versus 45&#46;5&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41; &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>&#41;&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0215" class="elsevierStylePara elsevierViewall">Referred to the survivors &#40;145 patients&#41; at discharge from the ICU&#44; we recorded a decrease over time in the resolution of renal failure&#44; an increase in the number of patients dependent upon IHD&#44; and a stable number of chronic cases with no need for IHD &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Fig&#46; 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0060" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Predictors of mortality and renal recovery</span><p id="par0220" class="elsevierStylePara elsevierViewall">In the 10 years of the study&#44; a total of 159 of the 304 patients died &#40;52&#46;3&#37;&#41;&#46; The variables found to be significant predictors of mortality in the univariate analysis were creatinine upon admission and creatinine at the start of the technique&#8211;both being higher among the survivors&#46; Likewise&#44; the origin of renal failure was identified as a significant variable&#59; specifically&#44; patients with ARF originating in hospital suffered greater mortality than those with community-acquired ARF &#40;<a class="elsevierStyleCrossRef" href="#tbl0015">Table 3</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0015"></elsevierMultimedia><p id="par0225" class="elsevierStylePara elsevierViewall">Septic shock as a cause of ARF also proved significant in the univariate analysis &#40;57&#46;9&#37; versus 44&#46;4&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;014&#41;&#46;</p><p id="par0230" class="elsevierStylePara elsevierViewall">Another factor adding to mortality was the renal replacement technique used&#46; In effect&#44; the mortality rate was higher among the patients subjected to continuous techniques versus only the intermittent mode or those patients subjected to both treatment modes&#46;</p><p id="par0235" class="elsevierStylePara elsevierViewall">In the multivariate analysis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; and after adjusting for age and the APACHE II score upon admission&#44; the variables independently related to mortality were the following&#58;<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0240" class="elsevierStylePara elsevierViewall">Creatinine upon admission &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;02&#59; OR 0&#46;77&#59; 95&#37;CI 0&#46;61&#8211;0&#46;97&#41;&#46; The survivors showed greater creatinine upon admission&#46;</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0245" class="elsevierStylePara elsevierViewall">The replacement therapy received&#46; Specifically&#44; intermittent treatment was a predictor of mortality versus those subjected to continuous therapy or both techniques &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;015&#59; OR 0&#46;37&#59; 95&#37;CI 0&#46;16&#8211;0&#46;87&#41;&#46;</p></li></ul></p><elsevierMultimedia ident="fig0015"></elsevierMultimedia><p id="par0250" class="elsevierStylePara elsevierViewall">Regarding the recovery of renal function among the survivors &#40;145 patients&#41;&#44; only 21&#46;4&#37; of the total patients &#40;31 subjects&#41; required IHD at discharge&#46; After excluding the patients &#40;34 subjects&#41; who already presented previous known renal failure &#40;creatinine<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41; from the group of survivors&#44; the percentage of patients requiring IHD at discharge decreased to 11&#37;&#46;</p><p id="par0255" class="elsevierStylePara elsevierViewall">The variables identified by the univariate analysis as being significantly associated to the need for IHD at discharge were creatinine upon admission&#44; creatinine at the start of the technique&#44; and patients with previous chronic renal failure&#46;</p><p id="par0260" class="elsevierStylePara elsevierViewall">The variables significantly associated to the recovery of renal function were septic shock as the origin of ARF and the replacement therapy received&#46; Specifically&#44; the subjects who received continuous treatment required IHD at discharge less often than those who received both techniques &#40;7&#46;1&#37; versus 26&#46;5&#37;&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;003&#41;&#46; There were no significant differences between the continuous and intermittent techniques &#40;<a class="elsevierStyleCrossRef" href="#tbl0020">Table 4</a>&#41;&#46;</p><elsevierMultimedia ident="tbl0020"></elsevierMultimedia><p id="par0265" class="elsevierStylePara elsevierViewall">In the multivariate logistic regression analysis &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Fig&#46; 3</a>&#41;&#44; the variables shown to be independently related to the need for IHD at discharge from the ICU were the following&#58;<ul class="elsevierStyleList" id="lis0010"><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0270" class="elsevierStylePara elsevierViewall">Creatinine upon admission &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;01&#59; OR 1&#46;98&#59; 95&#37;CI 1&#46;12&#8211;3&#46;48&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0275" class="elsevierStylePara elsevierViewall">The type of renal failure&#58; acute versus exacerbated chronic failure &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#60;<span class="elsevierStyleHsp" style=""></span>0&#46;005&#59; OR 0&#46;11&#59; 95&#37;CI 0&#46;04&#8211;0&#46;34&#41;&#46;</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0280" class="elsevierStylePara elsevierViewall">The continuous technique as treatment received versus the group subjected to both techniques &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;03&#59; OR 0&#46;18&#59; 95&#37;CI 0&#46;03&#8211;0&#46;85&#41;&#46;</p></li></ul></p></span></span></span><span id="sec0065" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Discussion</span><p id="par0285" class="elsevierStylePara elsevierViewall">The present study shows that the survival of critical patients requiring RRT due to renal failure has improved over time&#46; All the patients were treated according to the homogeneous protocol used in our Unit&#44; with variability being limited to changes in the therapy provided in accordance with the literature published during these years and the improvements in the global treatments provided in our Unit&#46;</p><p id="par0290" class="elsevierStylePara elsevierViewall">Although the global mortality of our patients has been similar to that described in the literature&#44; the main finding in our study was the decrease in mortality observed despite the fact that these are older patents&#44; with increased comorbidity and in very serious condition &#40;APACHE II<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>20&#41;&#46; These findings are in contrast to the published data affirming that mortality in patients with ARF remains high despite the medical advances&#44; because of the greater age of the patients&#44; greater comorbidity&#44; and a more serious patient condition&#46;<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a></p><p id="par0295" class="elsevierStylePara elsevierViewall">While old&#44; several publications offer results similar to our own&#46;<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">12&#44;13</span></a> Turney et al<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> compared patients with ARF &#40;admitted or not to the ICU&#41; treated in two different time periods&#44; and reported a decrease in mortality rate from 51&#37; to 42&#37;&#44; despite an increase in age and in the seriousness of the patient condition&#46; Bisenbach et al<span class="elsevierStyleItalic">&#46;</span><a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> in turn compared three consecutive time periods and likewise found a progressive drop in mortality rate from 69&#37; to 54&#37; and 48&#37;&#44; despite an increase in patient age&#46;</p><p id="par0300" class="elsevierStylePara elsevierViewall">In addition to the decrease in mortality&#44; we recorded a significant reduction in the days of therapy between the two time periods&#46; In our case&#44; considering similar characteristics in both groups and knowing that most patients presented ARF secondary to septic shock&#44; we attributed the decrease in mortality and in days of therapy to implementation of the treatment recommendations established from publication of the sepsis management guides&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">10</span></a></p><p id="par0305" class="elsevierStylePara elsevierViewall">This is justified by the greater number of cases of ARF originating in the community during the second time period&#44; which would correspond to the septic patients admitted during that period&#46;</p><p id="par0310" class="elsevierStylePara elsevierViewall">Of note is the observation that despite the decrease in days of therapy and in mortality&#44; the number of patients dependent upon IHD at discharge was higher in the recent period&#46; This is probably related to the larger number of patients with exacerbated chronic renal failure&#44; older age and a greater number of RFs for the development of renal failure&#46;</p><p id="par0315" class="elsevierStylePara elsevierViewall">Although this may be incongruent&#44; fewer days of therapy but more patients requiring IHD at discharge could be explained by the small number of patients needing RRT at discharge from the ICU&#44; together with the fact that many of these patients will not require IHD prior to hospital discharge&#46;</p><p id="par0320" class="elsevierStylePara elsevierViewall">These conclusions are complex and may be due to the difficult and scant definition of the concepts of ARF and exacerbated chronic renal failure&#46;</p><p id="par0325" class="elsevierStylePara elsevierViewall">Regarding the applied technique&#44; it is well known that the article published by Ronco et al&#46; in the year 2000<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> led to important changes in the management of our patients&#44; with the incorporation of an increased use of convection&#44; and a decrease in diffusion&#46; Furthermore&#44; the Acute Dialysis Quality Initiative&#44; on occasion of its third consensus conference&#44; recommended a dose of 35<span class="elsevierStyleHsp" style=""></span>ml&#47;kg&#47;h in septic patients &#40;evidence level II and degree of recommendation C&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a></p><p id="par0330" class="elsevierStylePara elsevierViewall">This caused many Units to replace their RRT machines with systems characterized by higher ultrafiltration flows&#44; and consequently involving higher pressures&#44; and to the great increase in the utilization of convective therapy&#46; A decade later&#44; in 2008 and 2009&#44;<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">17&#44;18</span></a> two studies have been published where despite the limitations involved&#44; the efficacy and safety of the treatment applied in recent years has been questioned&#44; and even new concepts have emerged such as &#8220;dialytrauma&#8221;&#8211;causing us to reflect upon and analyze how the high dialysis doses affect our patients and the rest of their treatment &#40;antibiotics&#44; nutrition&#44; etc&#46;&#41;&#46;<a class="elsevierStyleCrossRef" href="#bib0095"><span class="elsevierStyleSup">19</span></a> At present&#44; this has led us to assess the dialysis dose requirements of our patients on a daily basis&#44; introducing changes according to their evolution over time&#46;</p><p id="par0335" class="elsevierStylePara elsevierViewall">On analyzing the mortality predictors in our study population&#44; one of the variables correlated to increased mortality was creatinine upon admission&#8211;with higher values among the survivors&#46; Since most of the patients were septic cases&#44; we probably could deduce that since these subjects had higher creatinine levels&#44; they were placed on dialysis earlier &#40;though in our work&#44; and as a limiting element of the study&#44; the RRT starting time was not documented&#41;&#46;</p><p id="par0340" class="elsevierStylePara elsevierViewall">Recently&#44; however&#44; Chou et al&#46;<a class="elsevierStyleCrossRef" href="#bib0100"><span class="elsevierStyleSup">20</span></a> have published a propensity score analysis of the relationship between the RIFLE criteria<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">11</span></a> and the early or late start of replacement therapy&#46; The authors conclude that the mentioned classification is a poor predictor of the benefits of early or late initiation of RRT in the septic patient&#46;</p><p id="par0345" class="elsevierStylePara elsevierViewall">The other important finding in our study was that the therapy provided is independently associated with increased mortality&#8211;the provision of intermittent therapy only being a protective factor against mortality compared with continuous treatment or a combination of both techniques &#40;OR 0&#46;77&#41;&#46; Ours is an observational study&#59; this result therefore cannot be inferred from the logistic regression analysis&#46; Despite adjustment for the APACHE II score and age&#44; there are very important limitations&#59; given the protocol used in our Unit&#44; it was obvious that those patients who were only subjected to intermittent treatment&#44; as less seriously ill individuals&#44; also suffered lesser mortality&#46;</p><p id="par0350" class="elsevierStylePara elsevierViewall">Regarding the predictors of the recovery of renal function at discharge from the ICU&#44; our findings are not very different from those published to date&#46;<a class="elsevierStyleCrossRefs" href="#bib0020"><span class="elsevierStyleSup">4&#44;5&#44;7</span></a> At discharge from the ICU&#44; only 21&#46;4&#37; of the patients required IHD&#44; and if from these we exclude the chronic cases &#40;basal creatinine<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1&#46;8<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#44; then the percentage drops to 11&#37;&#46;</p><p id="par0355" class="elsevierStylePara elsevierViewall">In our case&#44; elevated creatinine values upon admission represented a risk factor for dependency upon IHD at discharge &#40;OR 1&#46;98&#41;&#46; On the other hand&#44; ARF versus exacerbated chronic renal failure was identified as a protective factor&#44; in the same way as continuous techniques as RRT versus the group of patients receiving both treatment modes&#46;</p><p id="par0360" class="elsevierStylePara elsevierViewall">Another important limitation appears here&#44; since the group of survivors did not include the patients who died&#44; and the great majority of those who died did so while receiving treatment with continuous techniques&#46; The patients only subjected to continuous treatment and which improved were therefore more likely to recover better renal function than the patients who were previously on IHD&#46; Here again&#44; however&#44; we cannot infer that the continuous techniques are related to improved recovery of renal function&#46;</p><p id="par0365" class="elsevierStylePara elsevierViewall">Our study has a number of important limitations&#46; A first limitation is the complexity of the variables and of the definitions involved&#8211;a situation still in wait of improvement after all these years of research in the field of renal failure&#46; On the other hand&#44; the time of the start of RRT has not been registered&#44; and no analysis has been made of the evolution of the SOFA score of the patient in the ICU&#44; or of other severity scores at the time of initiation of RRT&#46; As a result&#44; no extrapolation can be made to the APACHE II score of the same patient 24<span class="elsevierStyleHsp" style=""></span>h after admission to the ICU&#46;</p><p id="par0370" class="elsevierStylePara elsevierViewall">Despite the results of the regression analysis&#44; we cannot independently relate the different techniques to patient mortality and&#47;or the recovery of renal function&#44; since this is an observational study&#44; and the protocol used in our Unit precludes such inference&#46;</p><p id="par0375" class="elsevierStylePara elsevierViewall">Lastly&#44; another important limitation is the fact that no registry has been made of the complications of RRT&#44; for although such complications are well defined and are few&#44; they could also have been analyzed according to the technique used&#46;</p><p id="par0380" class="elsevierStylePara elsevierViewall">In conclusion&#44; critical patients requiring RRT have shown lower mortality rates in recent years&#44; and require fewer days of therapy&#46; This situation is probably attributable to improvements in the global management of these patients&#44; since many other factors in addition to RRT influence patient outcome&#46;</p></span><span id="sec0070" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle">Conflicts of interest</span><p id="par0385" class="elsevierStylePara elsevierViewall">The authors declare that they have no conflicts of interest&#46;</p></span></span>"
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          "titulo" => array:8 [
            0 => "Abstract"
            1 => "Objectives"
            2 => "Design"
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            4 => "Patients"
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            6 => "Results"
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          "titulo" => "Keywords"
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            0 => "Resumen"
            1 => "Objetivos"
            2 => "Dise&#241;o"
            3 => "&#193;mbito"
            4 => "Pacientes"
            5 => "Principales variables de inter&#233;s"
            6 => "Resultados"
            7 => "Conclusiones"
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          "titulo" => "Palabras clave"
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        4 => array:2 [
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          "titulo" => "Introduction"
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          "titulo" => "Patients and methods"
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            0 => array:2 [
              "identificador" => "sec0015"
              "titulo" => "Study population and period"
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            1 => array:2 [
              "identificador" => "sec0020"
              "titulo" => "Renal replacement therapy"
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            2 => array:2 [
              "identificador" => "sec0025"
              "titulo" => "Data collection"
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            3 => array:2 [
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              "titulo" => "Statistical analysis"
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          "titulo" => "Results"
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              "identificador" => "sec0040"
              "titulo" => "Characteristics of the patients&#47;evolutive analysis"
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                  "identificador" => "sec0045"
                  "titulo" => "Baseline population characteristics"
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                1 => array:2 [
                  "identificador" => "sec0050"
                  "titulo" => "Types and duration of renal replacement therapy"
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                2 => array:2 [
                  "identificador" => "sec0055"
                  "titulo" => "Mortality and recovery of renal function"
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                3 => array:2 [
                  "identificador" => "sec0060"
                  "titulo" => "Predictors of mortality and renal recovery"
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          "identificador" => "sec0065"
          "titulo" => "Discussion"
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          "titulo" => "Conflicts of interest"
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    "fechaRecibido" => "2011-08-01"
    "fechaAceptado" => "2012-01-14"
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            1 => "Intermittent hemodialysis"
            2 => "Hemofiltration"
            3 => "Septic shock"
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          "palabras" => array:4 [
            0 => "Tratamiento de reemplazo renal"
            1 => "Hemodialisis intermitente"
            2 => "Hemofiltraci&#243;n"
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        "titulo" => "Abstract"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objectives</span><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">To analyze the evolution of patients subjected to renal replacement therapy &#40;RRT&#41;&#44; and to determine risk factors associated with mortality and the recovery of renal function&#46;</p> <span class="elsevierStyleSectionTitle">Design</span><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">A prospective&#44; observational study of critically-ill patients&#46;</p> <span class="elsevierStyleSectionTitle">Setting</span><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Clinical&#8211;surgical Intensive Care Unit &#40;ICU&#41; of Sabadell Hospital &#40;Spain&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Patients</span><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Inclusion of all patients treated in our unit due to acute renal failure &#40;ARF&#41; requiring RRT&#46;</p> <span class="elsevierStyleSectionTitle">Primary variables of interest</span><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">We recorded epidemiological data&#44; severity using the APACHE II score&#44; days of the technique&#44; ICU mortality&#44; and renal function recovery&#46; The study period was divided into 2 parts&#58; part 1 &#40;2000&#8211;2004&#41; and part 2 &#40;2005&#8211;2009&#41;&#46; The 2 periods were compared using the Student&#39;s <span class="elsevierStyleItalic">t</span>-test for continuous variables and the chi-squared test for categorical variables&#46; Multiple regression analysis was performed to determine the risk factors for mortality and recovery of renal function&#46;</p> <span class="elsevierStyleSectionTitle">Results</span><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A total of 304 patients were treated&#46; Sepsis was the main etiology of ARF &#40;61&#37;&#41;&#44; involving principally respiratory and abdominal foci&#46; In the second period the convective technique and community-acquired ARF were far more prevalent than in the first period&#46; There were fewer days of therapy in the second period &#40;19&#46;7 versus 12&#46;3 days&#59; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;015&#41;&#46; Total ICU mortality was 52&#46;3&#37;&#44; with a decrease in the last period &#40;61&#46;9&#8211;45&#46;5&#37;&#58; <span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>&#46;003&#41;&#46; The risk factors associated with mortality were creatinine upon admission &#40;odds ratio &#91;OR&#93; 0&#46;77&#59; 95&#37; confidence interval &#91;95&#37;CI&#93; 0&#46;61&#8211;0&#46;97&#41; and treatment with IHD alone &#40;OR 0&#46;37&#44; 95&#37;CI 0&#46;16&#8211;0&#46;87&#41;&#46; Survivors had normal renal function at ICU discharge in 56&#46;7&#37; of the cases in the second period&#44; vs in 72&#46;9&#37; in the first period&#44; with more patients subjected to IHD in the second period &#40;10&#46;4&#37; versus 26&#46;8&#37;&#41;&#46; The factors related to the recovery of renal function were creatinine upon admission &#40;OR 1&#46;98&#44; 95&#37;CI 1&#46;12&#8211;3&#46;48&#41;&#44; acute renal failure &#40;OR 0&#46;11&#44; 95&#37;CI 0&#46;04&#8211;0&#46;34&#41; and treatment with continuous techniques &#40;OR 0&#46;18&#44; 95&#37;CI 0&#46;03&#8211;0&#46;85&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusions</span><p id="spar0040" class="elsevierStyleSimplePara elsevierViewall">Mortality among critically-ill patients subjected to RRT has improved in recent years&#46;</p>"
      ]
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        "titulo" => "Resumen"
        "resumen" => "<span class="elsevierStyleSectionTitle">Objetivos</span><p id="spar0045" class="elsevierStyleSimplePara elsevierViewall">Analizar la evoluci&#243;n de los pacientes con insuficiencia renal aguda tratados con terapia de reemplazo renal &#40;TRR&#41; y determinar los factores de riesgo asociados a mortalidad y recuperaci&#243;n de la funci&#243;n renal&#46;</p> <span class="elsevierStyleSectionTitle">Dise&#241;o</span><p id="spar0050" class="elsevierStyleSimplePara elsevierViewall">Estudio prospectivo y observacional en pacientes cr&#237;ticos&#46;</p> <span class="elsevierStyleSectionTitle">&#193;mbito</span><p id="spar0055" class="elsevierStyleSimplePara elsevierViewall">Unidad de Cuidados Intensivos &#40;UCI&#41; polivalente del Hospital de Sabadell&#46;</p> <span class="elsevierStyleSectionTitle">Pacientes</span><p id="spar0060" class="elsevierStyleSimplePara elsevierViewall">Inclusi&#243;n de los pacientes con insuficiencia renal que precisaron TRR en nuestra unidad&#46;</p> <span class="elsevierStyleSectionTitle">Principales variables de inter&#233;s</span><p id="spar0065" class="elsevierStyleSimplePara elsevierViewall">Registro de variables epidemiol&#243;gicas&#44; de gravedad &#40;APACHE II&#41; as&#237; como el tipo y duraci&#243;n de la TRR&#44; mortalidad y recuperaci&#243;n de la funci&#243;n renal al alta de UCI&#46; El periodo de estudio comprende 10 a&#241;os&#44; repartiendo la muestra en 2 periodos&#58; inicial &#40;2000-2004&#41; y reciente &#40;2005-2009&#41;&#46; An&#225;lisis estad&#237;stico comparativo de ambos periodos y an&#225;lisis de regresi&#243;n log&#237;stica m&#250;ltiple para determinar factores de riesgo de mortalidad y de recuperaci&#243;n de funci&#243;n renal&#46;</p> <span class="elsevierStyleSectionTitle">Resultados</span><p id="spar0070" class="elsevierStyleSimplePara elsevierViewall">An&#225;lisis de 304 pacientes&#46; Principal causa de ingreso la sepsis &#40;61&#37;&#41;&#44; siendo el foco respiratorio y el abdominal los m&#225;s frecuentes&#46; El origen comunitario de la insuficiencia renal y la t&#233;cnica convectiva se incrementaron en el periodo reciente&#46; Destaca un descenso de d&#237;as de terapia &#40;19&#44;7 a 12&#44;3&#59; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span>0&#44;015&#41;&#46; La mortalidad global en UCI fue de 52&#44;3&#37;&#44; siendo la principal causa el fallo multiorg&#225;nico&#44; objetivando un descenso entre ambos periodos &#40;61&#44;9 a 45&#44;5&#37;&#59; p<span class="elsevierStyleHsp" style=""></span><span class="elsevierStyleMonospace">&#61;</span>0&#44;003&#41;&#46; Los factores relacionados con la mortalidad fueron la creatinina al ingreso &#40;<span class="elsevierStyleItalic">odds ratio</span> &#91;OR&#93; 0&#44;77&#59; intervalo de confianza del 95&#37; &#91;IC95&#37;&#93; 0&#44;61-0&#44;97&#41; y el tratamiento solo con HDI &#40;OR 0&#44;37&#59; IC95&#37; 0&#44;16-0&#44;87&#41;&#46; De los supervivientes&#44; al alta de UCI&#44; en el periodo reciente destaca un aumento de los pacientes que quedan con dependencia de HD &#40;10&#44;4 versus 26&#44;8&#37;&#41;&#46; Los factores relacionados con la recuperaci&#243;n de la funci&#243;n renal fueron la creatinina al ingreso &#40;OR 1&#44;98&#59; IC95&#37; 1&#44;12-3&#44;48&#41;&#44; la insuficiencia renal aguda versus la cr&#243;nica agudizada &#40;OR 0&#44;11&#59; IC95&#37; 0&#44;04-0&#44;34&#41; y el tratamiento con t&#233;cnicas continuas &#40;OR 0&#44;18&#59; IC95&#37; 0&#44;03-0&#44;85&#41;&#46;</p> <span class="elsevierStyleSectionTitle">Conclusiones</span><p id="spar0075" class="elsevierStyleSimplePara elsevierViewall">La mortalidad de los pacientes cr&#237;ticos tratados con TRR ha mejorado en los &#250;ltimos a&#241;os&#46;</p>"
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        "etiqueta" => "&#9734;"
        "nota" => "<p class="elsevierStyleNotepara">Please cite this article as&#58; Navas A&#44; et al&#46; Terapia de reemplazo renal en paciente cr&#237;tico&#58; cambios evolutivos del tratamiento en los &#250;ltimos a&#241;os&#46; Med Intensiva&#46; 2012&#59;36&#58;540&#8211;7&#46;</p>"
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          "en" => "<p id="spar0085" class="elsevierStyleSimplePara elsevierViewall">Evolution of the recovery of renal function in the survivors &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>145&#41;&#46; Healing&#58; full recovery&#59; chronic&#58; partial recovery &#40;creatinine<span class="elsevierStyleHsp" style=""></span>&#62;<span class="elsevierStyleHsp" style=""></span>1&#46;5<span class="elsevierStyleHsp" style=""></span>mg&#47;dl&#41;&#59; Chronic HD&#58; need for IHD at discharge from the ICU &#40;<span class="elsevierStyleItalic">p</span><span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>0&#46;06&#41;&#46; IP&#58; initial period&#59; RP&#58; recent period&#46;</p>"
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Failure&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">87&#46;3&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">86&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
              ]
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                0 => "xTab8538.png"
              ]
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          "en" => "<p id="spar0095" class="elsevierStyleSimplePara elsevierViewall">Basal characteristics of the patients&#46;</p>"
        ]
      ]
      4 => array:7 [
        "identificador" => "tbl0010"
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          "leyenda" => "<p id="spar0110" class="elsevierStyleSimplePara elsevierViewall">HD&#58; hemodialysis&#59; CVVHDF&#58; continuous venous&#8211;venous hemodiafiltration&#59; CVVHF&#58; continuous venous&#8211;venous hemofiltration&#59; IP&#58; period initial&#59; RP&#58; recent period&#46;</p>"
          "tablatextoimagen" => array:1 [
            0 => array:2 [
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                0 => """
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">IP &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>126&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">RP &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>178&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;431&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CVVHF &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">36&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">50&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;013&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CVVHF AF &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">23&#46;6&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">&#60;0&#46;005&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">CVVHDF &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">53&#46;2&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">37&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">0&#46;004&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t">2 continuous techniques &#40;&#37;&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">16&#46;7&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">26&#46;4&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">0&#46;01&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">Days of therapy&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">19&#46;7<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&#46;7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t">12&#46;3<span class="elsevierStyleHsp" style=""></span>&#177;<span class="elsevierStyleHsp" style=""></span>7&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="char" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t">0&#46;01&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr></tbody></table>
                  """
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          "en" => "<p id="spar0105" class="elsevierStyleSimplePara elsevierViewall">Renal replacement therapy &#40;RRT&#41; techniques and days of therapy&#46;</p>"
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      ]
      5 => array:7 [
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        "tabla" => array:2 [
          "leyenda" => "<p id="spar0120" class="elsevierStyleSimplePara elsevierViewall">The creatinine values are reported as the mean and standard deviation&#46;</p>"
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            0 => array:2 [
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                0 => """
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                  \t\t\t\t" style="border-bottom: 2px solid black">&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Survivors &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>145&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t" style="border-bottom: 2px solid black">Deceased &#40;n<span class="elsevierStyleHsp" style=""></span>&#61;<span class="elsevierStyleHsp" style=""></span>159&#41;&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">3&#46;22 &#40;2&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">2&#46;16 &#40;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Creatinine at start of RRT &#40;mg&#47;dl&#41;</span>&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t">4&#46;58 &#40;2&#46;2&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">3&#46;92 &#40;1&#46;4&#41;&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;02&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleItalic">RIFLE &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Risk&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">62&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">37&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">54&#46;5&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">0&#46;68&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Failure&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t">47&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t">52&#46;5&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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                  \t\t\t\t  " align="" valign="\n
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                  \t\t\t\t">&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
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                  \t\t\t\t"><span class="elsevierStyleVsp" style="height:0.5px"></span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " colspan="4" align="left" valign="\n
                  \t\t\t\t\ttop\n
                  \t\t\t\t"><span class="elsevierStyleItalic">Origin ARF &#40;&#37;&#41;</span></td></tr><tr title="table-row"><td class="td" title="\n
                  \t\t\t\t\ttable-entry\n
                  \t\t\t\t  " align="left" valign="\n
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                  \t\t\t\t"><span class="elsevierStyleHsp" style=""></span>Hospital&nbsp;\t\t\t\t\t\t\n
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                  \t\t\t\t  " align="char" valign="\n
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                  \t\t\t\t">38&#46;1&nbsp;\t\t\t\t\t\t\n
                  \t\t\t\t</td><td class="td" title="\n
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