Patients with acute renal failure requiring dialysis have high morbidity and mortality rates. To summarize the current evidence and offer guidance in providing dialysis to these patients, the authors conducted a systematic review of the literature and identified 30 randomized, controlled trials (with data on a total of 3,218 patients) and eight prospective cohort studies (with data on a total of 2,868 patients) that used continuous renal replacement therapy or intermittent hemodialysis to treat acute renal failure. However, the studies' limitations-the more than 35 published definitions of acute renal failure that complicate comparisons, the limited understanding of acute renal failure's epidemiology, and poor design-made determining and recommending a management strategy problematic. The authors considered when to initiate dialysis, its dose, and its duration.

Metabolic disorders and electrolyte imbalances that haven't responded to other types of therapy are key indicators of renal failure, but changes in the level of serum creatinine remain the gold standard. Research related to critical timing for initiating dialysis is sparse. Comparative analysis of the 38 trials revealed nonsignificant differences in survival rates, the necessity of chronic dialysis, and hypotensive episodes. Of note, seven trials indicated that there was a significantly higher risk of death among patients with acute renal failure whose dialysis membrane was made of unsubstituted cellulose.

The crux of the matter. Data supporting best practices in the initiation, dose, and duration of dialysis could not be found in these studies. Recommendations for further research include developing a standardized definition of acute renal failure, creating well-designed studies focused on defining parameters, and developing clinical pathways for outcomes related to specific courses of illness rather than comparisons of methodologies.

Pannu N, et al. JAMA 2008;299(7):793-805.

Section Description

Evidence for Excellence is a periodic department showcasing new evidence-based practice guidelines and results of systematic literature reviews to help the nurse in practice.

Practice Guidelines

Systematic Review