Application of Continuous Renal Replacement Therapy: What Should We Consider Based on Existing Evidence?

Abstract

Background: Continuous renal replacement therapy (CRRT) is performed mainly in patients with acute kidney injury, severe sepsis, or septic shock. Evidence has emerged about the indications for and therapeutic conditions of CRRT. In this review, we focus on the evidence for CRRT to date. Summary: CRRT employs diffusion, convection and adsorption to remove solutes from plasma. Indications can be divided into renal and non-renal indications. Concrete renal indications have not yet been determined, except for life-threatening absolute indications. Modality selection is a point of debate. Intermittent renal replacement therapy is reportedly equivalent to CRRT in terms of overall survival. However, the selection of modality must consider individual circumstances. The optimal dosage of CRRT has proven to be lower than that previously recommended, and the dosage is almost the same as the one employed in the ‘real-world' setting. Patients treated by CRRT often have bleeding complications. In this situation, regional citrate anticoagulation can be used, but nafamostat is widely used in Japan. The right jugular vein is the most preferred vascular access site because it has the lowest likelihood of catheter malfunction. As for the complications of CRRT, hypophosphatemia and nutrient loss should be managed properly. When CRRT is no longer necessary, we should consider the appropriate timing of discontinuation. Key Messages: Even though CRRT is an established technique, several points remain under debate. Individualization of therapy should be considered in light of the changes in patient characteristics.

The impact of continuous renal replacement therapy on renal outcomes in dialysis-requiring acute kidney injury may be related to the baseline kidney function

“…The constant removal of solutes thus avoids sudden changes in plasma osmolality, especially in individuals with intracranial hypertension. Continuous modalities provide better adjustment of metabolic acidosis and metabolic control for hypercatabolic individuals, and induce possible immunomodulatory effects [27–29]. …”

The Role of Continuous Renal Replacement Therapy and Therapeutic Plasma Exchange in Sepsis

“…Adsorption by the CRRT membrane represents a third mechanism of clearance. 23 The Prospective Pediatric CRRT (ppCRRT) Registry, a multicenter observational study of 370 children on CRRT, evaluated current practices in pediatric CRRT modality choice across centers and showed that all modalities are commonly utilized: 48% CVVHDF, 21% CVVH, and 30% CVVHD. 24 The role of CRRT in sepsis serves can be evaluated from two major aspects: renal replacement therapy for AKI and immunomodulation.…”

Pharmacokinetics and outcome of tazobactam/piperacillin in Japanese patients undergoing low-flow continuous renal replacement therapy: dosage considerations

“…In Australia and New Zealand, the following specifications were reported: blood flow, 200 mL.min −1 and the amount of blood purification, 24.3 mL·kg −1 ·h −1 10. In Japan, the following procedure was reported: blood flow, 80 mL.min −1 and the median amount of blood purification, 16 mL·kg −1 ·h −1 11. These reports indicate that the values vary depending on the country, region, and institution.…”