Renal Replacement Therapy in Intensive Care Unit: 10 Commandments (original) (raw)

Renal replacement therapy for acute kidney injury in the intensive care unit

Nephrologie & Therapeutique, 2017

Renal replacement therapy for acute kidney injury has been used for more than 60 years. Except when life-threatening metabolic complications such as severe hyperkalaemia are present, renal replacement therapy initiation criteria are the subject of intense debate. Significant progress has been made with the publication of the AKIKI multicenter trial, which showed that a delayed renal replacement therapy initiation strategy (in the absence of life-threatening metabolic complications) was not associated with a difference in mortality compared to an early renal replacement therapy initiation strategy. In addition, this delayed strategy obviated the need for renal replacement therapy in almost 50% of cases was associated with a more rapid renal function recovery and with a lower incidence of catheter-bloodstream related infections. Research on renal replacement therapy modalities (continuous vs. intermittent renal replacement therapy, citrate vs. heparin anticoagulation, jugular vs. femoral catheterization) did not show any obvious superiority of one modality over another. Thus, the choice depends mainly on local considerations (patient recruitment, availability of modalities, staff experience). The criteria for renal replacement therapy discontinuation are still unclear due to difficulties in assessing renal function recovery. Urine output remains the main criteria in the decision to wean from renal replacement therapy. Pending the confirmation of AKIKI trial by similar studies in progress, it seems reasonable to choose a delayed renal replacement therapy initiation strategy under watchful surveillance in case of severe acute kidney injury in the absence of life-threatening metabolic complications.

ISCCM Guidelines on Acute Kidney Injury and Renal Replacement Therapy

Indian Journal of Critical Care Medicine

Acute kidney injury (AKI) is a complex syndrome with a high incidence and considerable morbidity in critically ill patients. Renal replacement therapy (RRT) remains the mainstay of treatment for AKI. There are at present multiple disparities in uniform definition, diagnosis, and prevention of AKI and timing of initiation, mode, optimal dose, and discontinuation of RRT that need to be addressed. The Indian Society of Critical Care Medicine (ISCCM) AKI and RRT guidelines aim to address the clinical issues pertaining to AKI and practices to be followed for RRT, which will aid the clinicians in their day-today management of ICU patients with AKI.

Renal Replacement Therapy in the Critical Care Setting

Critical Care Research and Practice, 2019

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.

Acute kidney injury and renal replacement therapy in the intensive care unit

Nursing in Critical Care, 2009

Background: Renal replacement therapy (RRT) is now offered as a routine treatment in most intensive care units (ICU) in the UK for patients suffering from acute kidney injury (AKI). It is important for all ICU staff to understand the underlying principles of the available therapeutic options and the possible complications thereof. Aims and objectives: The objective of this review was to provide an accessible theoretical and practical update on the management of RRT. In addition to a detailed discussion of the underlying principles and indications for the various modes of RRT, we will discuss the assessment of kidney function, possible complications and anticoagulation during RRT, following a review of the current literature. Search strategies: Pubmed, Medline and the Cumulative Index to Nursing and Allied Health Literature were searched using the keywords renal function, RRT, dialysis, renal failure kidney injury, together with intensive care, intensive therapy and critical care. We included only studies published in English from 1998 to 2008 and from these identified and included additional publications. The 12 most relevant publications are referenced in this review. Conclusion: AKI is associated with increased mortality in ICU, and RRT should be considered early in the disease process. Continuous haemofiltration is the most common modality of treatment in this group of patients, and a detailed knowledge of the management of such patients is required.

Renal Replacement Therapy in Critically Ill: Current Trend and New Direction

Bangladesh Critical Care Journal, 2015

Diagnosing and managing critically ill patients with renal dysfunction is an important part in the management of critically ill. Renal replacement therapy (RRT) is being widely used in intensive care. Acute kidney injury (AKI) is frequently present in critically ill patients of the intensive care unit (ICU) as a part of multiple organ dysfunction syndrome (MODS). These patients have various co-morbid conditions and are on various life-supportive modalities. Fluid overload and electrolyte and acid-base disturbances and drugs may further injure their organ systems. RRT plays a significant role in ICU in the treatment of patients with renal failure, acute as well as chronic. However, the term 'RRT' is not

Renal Replacement Therapy in Acute Kidney Injury: Which Mode and When?

Indian Journal of Critical Care Medicine, 2014

Renal replacement therapy (RRT) for acute kidney injury (AKI) patients in an intensive care unit (ICU) presents unique problems of providing biochemical and fluid removal in patients with unstable circulations, inotropes, and increased capillary permeability. Although no individual modality has been shown to confer a mortality benefit, it is assumed that continuous therapies like peritoneal dialysis (PD) and venovenous hemofiltration or hemodiafiltration may be better tolerated by the patient with hemodynamic instability, raised intracranial pressure (ICP), and liver failure. An individual patient may require more than one treatment in the course of his/her illness. The therapies offered may reflect available resources, local expertise, and cost constraints.

Renal replacement therapy in acute kidney injury

About 4% of intensive care unit (ICU) patients worldwide have acute kidney injury (AKI) and require renal replacement therapy (RRT). The choice of modality has expanded from intermittent hemodialysis (IHD) and peritoneal dialysis (PD), where solute clearance is by diffusion, to include continuous renal replacement therapy (CRRT) where convection is the predominant mode of clearance and sustained low-efficiency dialysis (SLED) which involves very slow diffusive clearance without hemodynamic compromise. SLED is considered equivalent to CRRT and is a much less expensive therapy. Early referral to nephrologist improves outcome but the effect of early RRT initiation is still unclear. Fluid overload seems to portend a bad outcome and the benefit of RRT early when there is fluid overload awaits confirmation in a study. The raging debate about dosing of RRT over the past decade seems to be over with the general consensus that increasing RRT dose above a CRRT dose of 20 mL/kg/min may not be beneficial. Heparin anticoagulation is least necessary for IHD. Regional anticoagulation with citrate is possible with need for careful monitoring of pH, ionized calcium and electrolytes. Although largely given up in the west, PD is still an important RRT modality. Various PD techniques are now available for tailoring therapy. PD is the RRT modality of choice in children but CRRT has been increasing in popularity. Newer exciting RRT modalities and other advances are evolving for the treatment of patients with AKI and future trials confirming their clinical utility and safety are awaited.