Slow low-efficiency extended hemodialysis in the management of refractory congestive heart failure and in critically ill patients

الملخص EN

Background : Chronic groin pain is a significant problem following tension free hernioplasty with a reported incidence ranging from 19% to 62.9%.

Quality of life studies have shown that chronic pain irrespective of severity can significantly interfere with normal daily activities where the condition can sometimes be debilitating and the treatment is often difficult and challenging.

Objective : To study the effect of prophylactic ilio-inguinal neurectomy on the incidence and severity of chronic groin pain following Lichtenstein tension free hernioplasty for inguinal hernia.

Methods : Forty male patients over 18 years old with unilateral inguinal hernia undergoing Lichtenstein hernia repair were randomized to receive either prophylactic ilio-inguinal neurectomy (group A) or ilio-inguinal nerve preservation (group B) during operation.

The primary outcome was the incidence of chronic groin pain at 6 months.

Secondary outcomes included the incidence of groin numbness assessed by self-filling questionnaire at 6 months .

All follow up and outcome measures were carried out at 1 and 6 months following surgery.

Results : There were no significant statistical difference between the two groups as regard postoperative pain after 1 and 6 months at rest, after various activities, and at normal daily activities.

No significant intergroup differences were found regarding the incidence of groin numbness at 1 and 6 months after the operation.

Conclusions : Prophylactic ilio-inguinal neurectomy should not be considered as a routine surgical step in hernioplasty as it did not decrease the incidence of postoperative groin pain over nerve preservation.

Background : For a long time, it has been claimed that continuous renal replacement therapy (CRRT) was superior to intermittent hemodialysis (IHD).

However, CRRT has several features that may not make it an ideal therapy for critically ill patients at all times.

Slow low-efficiency extended dialysis (SLED) emerged as a valuable alternative dialysis strategy which combines the advantages of CRRT with those of IHD.

Here, classic IHD is performed at low dialysate and blood flow rates, resulting in an improvement of tolerance at the expense of longer dialysis time.

Aim : Evaluation of the effect of SLED in refractory congestive heart failure (CHF) and in critically ill patients as regards : Patients´ tolerance, cardiovascular stability, small molecule clearance (urea and creatinine), ultrafiltration, use of anticoagulants, and on serum level of TNF-α.

Patients and Methods : SLED performed during the day was evaluated in 2 different groups of patients.

Group I : Ten refractory CHF patients with renal impairment.

Group II : Ten critically ill patients requiring renal replacement therapy.

A sterile saline-based bicarbonate-containing dialysate prepared just before use was passed into a hollow fiber polysalfone dialyzer at a flow rate of 30 ml / min.

Blood flow ranged from 120-150 ml / min and was driven by the blood pump of a standard hemodialysis machine.

Results : No patient developed further hemodynamic instability during the SLED sessions, or died due to the procedure.

There was significant reduction of blood urea and serum creatinine levels in both groups.

Body weight, assessed in group I, was significantly reduced after the completion of SLED sessions.

Echocardiography, done for patients in the same group, showed significant improvement of the echocardiographic parameters.

Serum levels of tumor necrosis factor-alpha (TNF-α) showed significant reduction only in group I.

Conclusion : SLED has a favorable outcome in patients with refractory CHF, tolerable even in critically ill patients, and offers a valuable and economic alternative to classical hemodialysis and CRRT in these patients.