Hemofiltration

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Hemofiltration
Haemofilter.png
Hemofilter ready for use.
Specialty nephrology
ICD-9-CM 39.95
MeSH D006440

Hemofiltration, also haemofiltration, is a renal replacement therapy which is used in the intensive care setting. It is usually used to treat acute kidney injury (AKI), but may be of benefit in multiple organ dysfunction syndrome or sepsis. [1] During hemofiltration, a patient's blood is passed through a set of tubing (a filtration circuit) via a machine to a semipermeable membrane (the filter) where waste products and water (collectively called ultrafiltrate) are removed by convection. Replacement fluid is added and the blood is returned to the patient. [2]

Contents

As in dialysis, in hemofiltration one achieves movement of solutes across a semi-permeable membrane. However, solute movement with hemofiltration is governed by convection rather than by diffusion. With hemofiltration, dialysate is not used. Instead, a positive hydrostatic pressure drives water and solutes across the filter membrane from the blood compartment to the filtrate compartment, from which it is drained. Solutes, both small and large, get dragged through the membrane at a similar rate by the flow of water that has been engendered by the hydrostatic pressure. Thus convection overcomes the reduced removal rate of larger solutes (due to their slow speed of diffusion) seen in hemodialysis.

Hemodiafiltration

Hemofiltration is sometimes used in combination with hemodialysis, when it is termed hemodiafiltration. Blood is pumped through the blood compartment of a high flux dialyzer, and a high rate of ultrafiltration is used, so there is a high rate of movement of water and solutes from blood to dialysate that must be replaced by substitution fluid that is infused directly into the blood line. However, dialysis solution is also run through the dialysate compartment of the dialyzer. The combination is theoretically useful because it results in good removal of both large and small molecular weight solutes.[ citation needed ]

Intermittent vs. continuous

These treatments can be given intermittently, or continuously. The latter is usually done in an intensive care unit setting. There may be little difference in clinical and health economic outcome between the two in the context of acute kidney failure. [3] [4]

On-line intermittent hemofiltration (IHF) or hemodiafiltration (IHDF)

Either of these treatments can be given in outpatient dialysis units, three or more times a week, usually 3–5 hours per treatment. IHDF is used almost exclusively, with only a few centers using IHF. With both IHF or IHDF, the substitution fluid is prepared on-line from dialysis solution by running dialysis solution through a set of two membranes to purify it before infusing it directly into the blood line. In the United States, regulatory agencies have not yet approved on-line creation of substitution fluid because of concerns about its purity. For this reason, hemodiafiltration, had historically never been used in an outpatient setting in the United States.[ citation needed ]

Continuous hemofiltration or hemodiafiltration (CHDF)

Continuous hemofiltration (CHF) was first described in a 1977 paper by Kramer et al. as a treatment for fluid overload. [5] Hemofiltration is most commonly used in an intensive care unit setting, where it is either given as 8- to 12-hour treatments, so called SLEF (slow extended hemofiltration), or as CHF (continuous hemofiltration), also sometimes called continuous veno-venous hemofiltration (CVVH) or continuous renal replacement therapy (CRRT). [6] [7] Hemodiafiltration (SLED-F or CHDF or CVVHDF) also is widely used in this fashion. In the United States, the substitution fluid used in CHF or CHDF is commercially prepared, prepackaged, and sterile (or sometimes is prepared in the local hospital pharmacy), avoiding regulatory issues of on-line creation of replacement fluid from dialysis solution.

With slow continuous therapies, the blood flow rates are usually in the range of 100-200 ml/min, and access is usually achieved through a central venous catheter placed in one of the large central veins. In such cases a blood pump is used to drive blood flow through the filter. Native access for hemodialysis (e.g. AV fistulas or grafts) are unsuitable for CHF because the prolonged residence of the access needles required might damage such accesses.

The length of time before the circuit clots and becomes unusable, often referred to as circuit life, can vary depending on the medication used to keep blood from clotting. Heparin and regional citrate are often used, though heparin carries a higher risk of bleeding. [8] However, a comprehensive analysis of audit data from intensive care units in the UK revealed that, compared with heparin, citrate-based drugs were not associated with fewer deaths among patients with acute kidney injury after 90 days of treatment. Citrate-based drugs were, however, associated with a substantially higher cost of treatment. [9] [10]

History of Continuous Renal Replacement Therapy

Before implementing continuous renal replacement therapy (CRRT), acute renal failure (ARF) in critically ill, multiple organ failure patients was managed by intermittent hemodialysis and the mortality rate was very high. [11] Hemodialysis is effective in clearance and ultrafiltration, but it has deleterious effects on hemodynamic stability. [12] In 1971, Lee Henderson described the basis for convective transport in blood purification techniques. Subsequently, in 1974 he described hemodiafiltration combining convection and diffusion. These seminal papers represented the basis for the development of chronic hemodiafiltration by Leber and continuous arteriovenous hemofiltration (CAVH) by Peter Kramer. [13]

With his team, Peter Kramer (Died unexpectedly in 1984), had actually first reported the use of continuous hemofiltration in Germany in 1977. [14] Peter Kramer in ASAIO presented a paper describing the use of arteriovenous hemofiltration in the management of ARF. [15] Kramer tried that as a mean of managing diuretic-resistant fluid overload. Kramer described his experience of attaching a microporous hemofilter to the femoral artery and vein, and flowing blood through it at around 100 ml/minuets Liters of plasma filtrate poured out. He replaced it with an infusion of electrolyte solution. [16] Kramer explained that this could be done continuously, avoiding the volume shifts and other problems of intermittent hemodialysis. For those in the audience who cared for patients with anuric ARF, this was an epiphany of thunderbolt proportions. [17] He used a hollow fiber “haemofilter” that originally designed as an alternative to HD for chronic renal failure and produced 300-600 ml/hour of ultrafiltrate by convection. The simple, pumpless system made use of temporary dialysis catheters sited in the patient’s femoral artery and vein and could be rapidly established in critically ill patients. [18] Kramer explained that this could be done continuously, avoiding the volume shifts and other problems of intermittent hemodialysis. For those in the audience who cared for patients with anuric ARF, this was an epiphany of thunderbolt proportions. [19] He used a hollow fiber “haemofilter” that originally designed as an alternative to HD for chronic renal failure and produced 300-600 ml/hour of ultrafiltrate by convection. The simple, pumpless system made use of temporary dialysis catheters sited in the patient’s femoral artery and vein and could be rapidly established in critically ill patients. Using an isotonic salt solution for fluid replacement, continuous arteriovenous hemofiltration (CAVH) was soon extended to the management of ARF. In 1982, Kramer presented his experience with its use in more than 150 intensive care patients at a meeting of the American Society for Artificial Internal Organs(ASAIO). [20] Before that, Henderson et al and Knopp, had studied hemofiltration in animals and as an alternative to dialysis in chronic renal failure, but it was really Peter Kramer’s report in ASAIO meeting in 1982 that stimulated many of nephrologists and intensivists to undertake the serious evaluation of CAVH in ARF in the ICU. [21]

At first, in CAVH, the prescribed ultrafiltration rate was achieved manually by arranging the filtrate bag at the right height, thereby changing the negative pressure caused by the filtrate column. The replacement fluid was also regulated manually. Few years later, CAVH was developed in several centers for managing ARF in critically ill patients with multiple organ failure. In 1986, it has been reported that CAVH improve the patient survival from 9% to 38% with full nutrition in ARF. [22] Moreover, a workshop presented at ASAIO in 1988 summarized the development and role of continuous hemofiltration. [23] Since late 1980s, continuous renal replacement therapy (CRRT) has been studied extensively. In 1982, the use of CAVH in Vicenza was extended for the first time to a neonate with the application of specific minifilters . Two years later, CAVH began to be used to treat septic patients, burn patients and patients after transplantation and cardiac surgery, even with regional citrate anticoagulation. [24] In 1986, the term continuous renal replacement therapy was applied to all these continuous approaches. [25] The technology and terminology were expanded to include slow continuous ultrafiltration for fluid removal without replacement, continuous arteriovenous hemodialysis (CAVHD), and continuous arteriovenous hemodiafiltration. [26] Meanwhile, clinical and technical limitations of CAVH spurred new research and the discovery of new treatments, leading to the development of continuous veno-venous hemofiltration (CVVH), continuous veno-venous hemodialysis (CVVHD) and continuous veno-venous hemodiafiltration (CVVHDF). The low depurative efficiency was overcome by applying filters with two ports in the dialysate/filtrate compartment and through the use of counter-current dialysate flow, allowing the addition of diffusion and the birth of continuous arteriovenous hemodiafiltration or hemodialysis (CAVHDF or CAVHD). [27]

Development of double-lumen venous catheters and peristaltic blood pumps was invented in the mid-1980s, when CVVH was proposed. The presence of a pump that generated negative pressure in part of the circuit made it necessary to add a device to detect the presence of air and a sensor to monitor the pressure in the circuit, to avoid, respectively, air embolisms and circuit explosion in case of coagulation or obstruction of the venous line. Later, ultrafiltrate and replacement pumps and a heater were added to the circuit. [28] The development of CVVH allows to increase the exchange volumes, and subsequently, the depurative efficiency. The use of counter-current dialysate flow led to further improvements and the birth of CVVHD and CVVHDF. [29] Now Continuous renal replacement therapy has become the mainstay of management of renal failure for multiple organ failure patients in the ICU. [30]

Information technology and precision medicine have recently furthered the evolution of CRRT, providing the possibility of collecting data in large databases and evaluating policies and practice patterns. The application of artificial intelligence and enhanced human intelligence programs to the analysis of big data has further moved the front of research ahead, providing the possibility of creating silica-trials and finding answers to patients’ unmet clinical needs. The opportunity to evaluate the endophenotype of the patient makes it possible to adjust treatments and techniques by implementing the concept of precision CRRT. This allows clinicians to normalize outcomes and results among different populations or individuals and establish optimal and personalized care [31]

See also

Related Research Articles

<span class="mw-page-title-main">Kidney dialysis</span> Removal of nitrogenous waste and toxins from the body in place of or to augment the kidney

Kidney dialysis is the process of removing excess water, solutes, and toxins from the blood in people whose kidneys can no longer perform these functions naturally. This is referred to as renal replacement therapy. The first successful dialysis was performed in 1943.

<span class="mw-page-title-main">Rhabdomyolysis</span> Human disease (condition) in which damaged skeletal muscle breaks down rapidly

Rhabdomyolysis is a condition in which damaged skeletal muscle breaks down rapidly. Symptoms may include muscle pains, weakness, vomiting, and confusion. There may be tea-colored urine or an irregular heartbeat. Some of the muscle breakdown products, such as the protein myoglobin, are harmful to the kidneys and can cause acute kidney injury.

<span class="mw-page-title-main">Kidney failure</span> Disease where the kidneys fail to adequately filter waste products from the blood

Kidney failure, also known as end-stage kidney disease, is a medical condition in which the kidneys can no longer adequately filter waste products from the blood, functioning at less than 15% of normal levels. Kidney failure is classified as either acute kidney failure, which develops rapidly and may resolve; and chronic kidney failure, which develops slowly and can often be irreversible. Symptoms may include leg swelling, feeling tired, vomiting, loss of appetite, and confusion. Complications of acute and chronic failure include uremia, hyperkalaemia, and volume overload. Complications of chronic failure also include heart disease, high blood pressure, and anaemia.

<span class="mw-page-title-main">Uremia</span> Type of kidney disease, urea in the blood

Uremia is the term for high levels of urea in the blood. Urea is one of the primary components of urine. It can be defined as an excess in the blood of amino acid and protein metabolism end products, such as urea and creatinine, which would be normally excreted in the urine. Uremic syndrome can be defined as the terminal clinical manifestation of kidney failure. It is the signs, symptoms and results from laboratory tests which result from inadequate excretory, regulatory, and endocrine function of the kidneys. Both uremia and uremic syndrome have been used interchangeably to denote a very high plasma urea concentration that is the result of renal failure. The former denotation will be used for the rest of the article.

<span class="mw-page-title-main">Hemodialysis</span> Medical procedure for purifying blood

Hemodialysis, also spelled haemodialysis, or simply dialysis, is a process of purifying the blood of a person whose kidneys are not working normally. This type of dialysis achieves the extracorporeal removal of waste products such as creatinine and urea and free water from the blood when the kidneys are in a state of kidney failure. Hemodialysis is one of three renal replacement therapies. An alternative method for extracorporeal separation of blood components such as plasma or cells is apheresis.

<span class="mw-page-title-main">Acute kidney injury</span> Medical condition

Acute kidney injury (AKI), previously called acute renal failure (ARF), is a sudden decrease in kidney function that develops within 7 days, as shown by an increase in serum creatinine or a decrease in urine output, or both.

<span class="mw-page-title-main">Chronic kidney disease</span> Medical condition

Chronic kidney disease (CKD) is a type of kidney disease in which a gradual loss of kidney function occurs over a period of months to years. Initially generally no symptoms are seen, but later symptoms may include leg swelling, feeling tired, vomiting, loss of appetite, and confusion. Complications can relate to hormonal dysfunction of the kidneys and include high blood pressure, bone disease, and anemia. Additionally CKD patients have markedly increased cardiovascular complications with increased risks of death and hospitalization.

<span class="mw-page-title-main">Peritoneal dialysis</span> Type of dialysis

Peritoneal dialysis (PD) is a type of dialysis that uses the peritoneum in a person's abdomen as the membrane through which fluid and dissolved substances are exchanged with the blood. It is used to remove excess fluid, correct electrolyte problems, and remove toxins in those with kidney failure. Peritoneal dialysis has better outcomes than hemodialysis during the first couple of years. Other benefits include greater flexibility and better tolerability in those with significant heart disease.

<span class="mw-page-title-main">Dialysis catheter</span>

A dialysis catheter is a catheter used for exchanging blood to and from a hemodialysis machine and a patient.

An extracorporeal is a medical procedure which is performed outside the body. Extracorporeal devices are the artificial organs that remain outside the body while treating a patient. Extracorporeal devices are useful in hemodialysis and cardiac surgery.

<span class="mw-page-title-main">Home hemodialysis</span>

Home hemodialysis (HHD) is the provision of hemodialysis to purify the blood of a person whose kidneys are not working normally, in their own home. One advantage to doing dialysis at home is that it can be done more frequently and slowly, which reduces the "washed out" feeling and other symptoms caused by rapid ultrafiltration, and it can often be done at night, while the person is sleeping.

Artificial kidney is often a synonym for hemodialysis, but may also refer to the other renal replacement therapies that are in use and/or in development. This article deals mainly with bioengineered kidneys/bioartificial kidneys that are grown from renal cell lines/renal tissue.

Renal replacement therapy (RRT) is therapy that replaces the normal blood-filtering function of the kidneys. It is used when the kidneys are not working well, which is called kidney failure and includes acute kidney injury and chronic kidney disease. Renal replacement therapy includes dialysis, hemofiltration, and hemodiafiltration, which are various ways of filtration of blood with or without machines. Renal replacement therapy also includes kidney transplantation, which is the ultimate form of replacement in that the old kidney is replaced by a donor kidney.

<span class="mw-page-title-main">Ultrafiltration (kidney)</span> Filtration by a semi-permeable membrane

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Nils Alwall was a Swedish professor at Lund University, Sweden. He was a pioneer in hemodialysis and the inventor of one of the first practical dialysis machines. Alwall pioneered the technique of ultrafiltration and introduced the principle of hemofiltration. Alwall is referred to as the "father of extracorporeal blood treatment."

<span class="mw-page-title-main">Robert Provenzano</span> American physician

Robert Provenzano is an American nephrologist. He is also an Associate Clinical Professor of Medicine at Wayne State University School of Medicine.

Aluminium toxicity in people on dialysis is a problem for people on haemodialysis. Aluminium is often found in unfiltered water used to prepare dialysate. The dialysis process does not efficiently remove excess aluminium from the body, so it may build up over time. Aluminium is a potentially toxic metal, and aluminium poisoning may lead to mainly three disorders: aluminium-induced bone disease, microcytic anemia and neurological dysfunction (encephalopathy). Such conditions are more prominently observed in people with chronic kidney failure and especially in people on haemodialysis.

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Fritz Scheler was a German internist, nephrologist and university professor. He was a pioneer in the field of hemofiltration treatment and helped found an institute for drug law at the University of Göttingen.

References

  1. ↑ Cruz D, Bellomo R, Kellum J, de Cal M, Ronco C (2008). "The future of extracorporeal support". Critical Care Medicine. 36 (Suppl): S243–S252. doi:10.1097/CCM.0b013e318168e4f6. PMID   18382201. S2CID   7896249.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  2. ↑ Hoffmann JN, Faist E (2001). "Removal of mediators by continuous hemofiltration in septic patients". World Journal of Surgery. 25 (5): 651–659. doi:10.1007/s002680020027. PMID   11369995. S2CID   10197867.
  3. ↑ Pannu N, Klarenbach S, Wiebe N, Manns B, Tonelli M (2008). "Renal replacement therapy in patients with acute renal failure". JAMA. 299 (7): 793–805. doi:10.1001/jama.299.7.793. PMID   18285591.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  4. ↑ Singh, Ambrish; Hussain, Salman; Kher, Vijay; Palmer, Andrew J.; Jose, Matthew; Antony, Benny (2021). "A systematic review of cost-effectiveness analyses of continuous versus intermittent renal replacement therapy in acute kidney injury". Expert Review of Pharmacoeconomics & Outcomes Research. 22 (1): 1–9. doi:10.1080/14737167.2021.1916471. PMID   33934689. S2CID   233484979.
  5. ↑ Kramer P, Wigger W, Rieger J, Matthaei D, Scheler F (1977). "Arteriovenous haemofiltration: a new and simple method for treatment of over-hydrated patients resistant to diuretics". Klinische Wochenschrift. 55 (22): 1121–1122. doi:10.1007/BF01477940. PMID   592681. S2CID   23461753.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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  8. ↑ Wu M, Hsu Y, Bai C, Lin Y, Wu C, Tam K (2012). "Regional citrate versus heparin anticoagulation for continuous renal replacement therapy: a meta-analysis of randomized controlled trials". American Journal of Kidney Diseases. 59 (6): 810–818. doi:10.1053/j.ajkd.2011.11.030. PMID   22226564.
  9. ↑ "No benefit from citrate anticoagulation for treatment of kidney injury". NIHR Evidence. 2022-09-22. doi:10.3310/nihrevidence_53421. S2CID   252488546 . Retrieved 2022-10-05.
  10. ↑ Gould, Doug W; Doidge, James; Sadique, M Zia; Borthwick, Mark; Hatch, Robert; Caskey, Fergus J; Forni, Lui; Lawrence, Robert F; MacEwen, Clare; Ostermann, Marlies; Mouncey, Paul R; Harrison, David A; Rowan, Kathryn M; Young, J Duncan; Watkinson, Peter J (February 2022). "Heparin versus citrate anticoagulation for continuous renal replacement therapy in intensive care: the RRAM observational study". Health Technology Assessment. 26 (13): 1–58. doi:10.3310/ZXHI9396. ISSN   1366-5278. PMC   8899910 . PMID   35212260.
  11. ↑ Stott, R.B.; Ogg, C.S.; Cameron, J.S.; Bewick, M. (July 1972). "WHY THE PERSISTENTLY HIGH MORTALITY IN ACUTE RENAL FAILURE ?". The Lancet. 300 (7767): 75–79. doi:10.1016/s0140-6736(72)91562-0. ISSN   0140-6736.
  12. ↑ Manns, M.; Sigler, M. H.; Teehan, B. P. (March 1996). "RENAL FUNCTION CHANGES DURING INTERMITTENT HEMODIALYSIS (IHD) VERSUS CONTINUOUS HEMODIALYSIS (CWHD) IN ACUTE RENAL FAILURE (ARF)". ASAIO Journal. 42 (2): 78. doi: 10.1097/00002480-199603000-00292 . ISSN   1058-2916.
  13. ↑ Samoni, Sara; Husain-Syed, Faeq; Villa, Gianluca; Ronco, Claudio (2021-12-29). "Continuous Renal Replacement Therapy in the Critically Ill Patient: From Garage Technology to Artificial Intelligence". Journal of Clinical Medicine. 11 (1): 172. doi: 10.3390/jcm11010172 . ISSN   2077-0383. PMC   8745413 .
  14. ↑ Kramer, P.; Wigger, W.; Rieger, J.; Matthaei, D.; Scheler, F. (November 1977). "Arteriovenous haemofiltration: A new and simple method for treatment of over-hydrated patients resistant to diuretics". Klinische Wochenschrift. 55 (22): 1121–1122. doi:10.1007/bf01477940. ISSN   0023-2173.
  15. ↑ Schrader, J.; Kaiser, H.; Eisenhauer, T.; Kramer, P.; Köstering, H.; Scheler, F. (1985), "Anticoagulation in Continuous Arteriovenous Hemofiltration", Arteriovenous Hemofiltration, Berlin, Heidelberg: Springer Berlin Heidelberg, pp. 72–83, ISBN   978-3-540-15317-7 , retrieved 2023-10-05
  16. ↑ Featherstone, Peter J; Ball, Christine M (May 2019). "A brief history of haemodialysis and continuous renal replacement therapy". Anaesthesia and Intensive Care. 47 (3): 220–222. doi: 10.1177/0310057x19853391 . ISSN   0310-057X.
  17. ↑ Bartlett, Robert H. (May 2018). "The Origins of Continuous Renal Replacement Therapy". ASAIO Journal. 64 (3): 427–430. doi:10.1097/mat.0000000000000573. ISSN   1058-2916.
  18. ↑ Featherstone, Peter J; Ball, Christine M (May 2019). "A brief history of haemodialysis and continuous renal replacement therapy". Anaesthesia and Intensive Care. 47 (3): 220–222. doi: 10.1177/0310057x19853391 . ISSN   0310-057X.
  19. ↑ Bartlett, Robert H. (May 2018). "The Origins of Continuous Renal Replacement Therapy". ASAIO Journal. 64 (3): 427–430. doi:10.1097/mat.0000000000000573. ISSN   1058-2916.
  20. ↑ Featherstone, Peter J; Ball, Christine M (May 2019). "A brief history of haemodialysis and continuous renal replacement therapy". Anaesthesia and Intensive Care. 47 (3): 220–222. doi: 10.1177/0310057x19853391 . ISSN   0310-057X.
  21. ↑ Bartlett, Robert H. (May 2018). "The Origins of Continuous Renal Replacement Therapy". ASAIO Journal. 64 (3): 427–430. doi:10.1097/mat.0000000000000573. ISSN   1058-2916.
  22. ↑ Mault, J. R.; Bartlett, R. H. (1985), "Energy Balance and Survival in Patients with Acute Renal Failure", Arteriovenous Hemofiltration, Berlin, Heidelberg: Springer Berlin Heidelberg, pp. 154–160, ISBN   978-3-540-15317-7 , retrieved 2023-10-05
  23. ↑ Bartlett, R. (1986), "Nutrition in Acute Renal Failure: Treatment Made Possible by Continuous Arteriovenous Hemofiltration (CAVH)", Acute Continuous Renal Replacement Therapy, Boston, MA: Springer US, pp. 173–183, ISBN   978-1-4612-9422-1 , retrieved 2023-10-05
  24. ↑ Samoni, Sara; Husain-Syed, Faeq; Villa, Gianluca; Ronco, Claudio (2021-12-29). "Continuous Renal Replacement Therapy in the Critically Ill Patient: From Garage Technology to Artificial Intelligence". Journal of Clinical Medicine. 11 (1): 172. doi: 10.3390/jcm11010172 . ISSN   2077-0383. PMC   8745413 .
  25. ↑ Bartlett, Robert H. (May 2018). "The Origins of Continuous Renal Replacement Therapy". ASAIO Journal. 64 (3): 427–430. doi:10.1097/mat.0000000000000573. ISSN   1058-2916.
  26. ↑ Ronco, Claudio (2017-05-31). "Continuous Renal Replacement Therapy: Forty-year Anniversary". The International Journal of Artificial Organs. 40 (6): 257–264. doi: 10.5301/ijao.5000610 . ISSN   0391-3988. PMC   6159848 .
  27. ↑ Samoni, Sara; Husain-Syed, Faeq; Villa, Gianluca; Ronco, Claudio (2021-12-29). "Continuous Renal Replacement Therapy in the Critically Ill Patient: From Garage Technology to Artificial Intelligence". Journal of Clinical Medicine. 11 (1): 172. doi: 10.3390/jcm11010172 . ISSN   2077-0383. PMC   8745413 .
  28. ↑ Henderson, Lee W. (1985), "Discovery and Relative Importance of Continuous Arteriovenous Hemofiltration", Arteriovenous Hemofiltration, Berlin, Heidelberg: Springer Berlin Heidelberg, pp. 1–2, ISBN   978-3-540-15317-7 , retrieved 2023-10-05
  29. ↑ Samoni, Sara; Husain-Syed, Faeq; Villa, Gianluca; Ronco, Claudio (2021-12-29). "Continuous Renal Replacement Therapy in the Critically Ill Patient: From Garage Technology to Artificial Intelligence". Journal of Clinical Medicine. 11 (1): 172. doi: 10.3390/jcm11010172 . ISSN   2077-0383. PMC   8745413 .
  30. ↑ PAGANINI, EMIL P.; SUHOZA, KAREN; SWANN, SAMUEL; GOLDING, LEONARD; NAKAMOTO, SATORU (July 1986). "Continuous Renal Replacement Therapy in Patients with Acute Renal Dysfunction Undergoing Intraaortic Balloon Pump and/or Left Ventricular Device Support". ASAIO Transactions. 32 (1): 414–417. doi:10.1097/00002216-198609000-00005. ISSN   0889-7190.
  31. ↑ Samoni, Sara; Husain-Syed, Faeq; Villa, Gianluca; Ronco, Claudio (2021-12-29). "Continuous Renal Replacement Therapy in the Critically Ill Patient: From Garage Technology to Artificial Intelligence". Journal of Clinical Medicine. 11 (1): 172. doi: 10.3390/jcm11010172 . ISSN   2077-0383. PMC   8745413 .
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