Renal Replacement Therapy in the Critical Care Setting.

Renal replacement therapy (RRT) is frequently required to manage critically ill patients with acute kidney injury (AKI). There is limited evidence to support the current practice of RRT in intensive care units (ICUs). Recently published randomized control trials (RCTs) have further questioned our understanding of RRT in critical care. The optimal timing and dosing continues to be debatable; however, current evidence suggests delayed strategy with less intensive dosing when utilising RRT. Various modes of RRT are complementary to each other with no definite benefits to mortality or renal function preservation. Choice of anticoagulation remains regional citrate anticoagulation in continuous renal replacement therapy (CRRT) with lower bleeding risk when compared with heparin. RRT can be used to support resistant cardiac failure, but evolving therapies such as haemoperfusion are currently not recommended in sepsis.

Glomerular disease recurrence in second and subsequent kidney transplants.

INTRODUCTION: Primary glomerular diseases such as primary focal segmental glomerular sclerosis (FSGS), IgA Nephropathy and membrano-proliferative glomerulonephritis (MPGN) may recur in renal transplants, and can potentially lead to graft failure. The rate of recurrence in second and subsequent renal transplants, following failure of the first graft due to recurrence, is unclear. METHODS: A retrospective review of the Irish transplant database from 1982 to 2009 was performed. Patients were included for analysis if their first graft failed due to biopsy-confirmed recurrent glomerular disease (primary FSGS, IgA nephropathy or MPGN) and they underwent subsequent re-transplantation. RESULTS: 3,330 deceased and living renal transplants were performed during the time period in question. 33 patients had a deceased donor renal transplant following recurrence of primary FSGS, IgA nephropathy or MPGN causing first graft failure. Clinically significant disease recurrence was seen in 44% of re-transplants at 10 years. Median second graft survival in this group was 9.1 years. The median graft survival was 10.5 years for all other re-transplants performed in Ireland during the same time period. CONCLUSION: Clinically significant disease recurrence does not necessarily affect re-transplants following loss of the first graft to disease recurrence. Selected patients who experience first graft failure due to recurrent glomerular disease should not be precluded from receiving a second transplant.