Prescription of CRRT: a pathway to optimize therapy

Abstract

Severe acute kidney injury (AKI), especially when caused or accompanied by sepsis, is associated with prolonged hospitalization, progression to chronic kidney disease (CKD), financial burden, and high mortality rate. Continuous renal replacement therapy (CRRT) is a predominant form of renal replacement therapy (RRT) in the intensive care unit (ICU) due to its accurate volume control, steady acid-base and electrolyte correction, and achievement of hemodynamic stability. This manuscript reviews the different aspects of CRRT prescription in critically ill patients with severe AKI, sepsis, and multiorgan failure in ICU. These include the choice of CRRT versus Intermittent and extended hemodialysis (HD), life of the filter/dialyzer including assessment of filtration fraction, anticoagulation including regional citrate anticoagulation (RCA), prescribed versus delivered CRRT dose, vascular access management, timing of initiation and termination of CRRT, and prescription in AKI/sepsis including adsorptive methods of removing endotoxins and cytokines.

Acute Kidney Injury in Septic Patients Treated by Selected Nephrotoxic Antibiotic Agents—Pathophysiology and Biomarkers—A Review

“…Hemoadsorption with CytoSorb can be used predominantly in patients suffering from septic shock with careful decision-making, according to the APACHE II score. The basic principle of these blood purification devices, using more effective membranes or columns incorporated in CRRT, is removal of pro-inflammatory cytokines (e.g., IL-6, IL-8, TNFα) and endotoxins to stabilize the patient’s hemodynamics and decrease the need for vasopressor therapy [ 87 ]. Preserving adequate fluid balance, net ultrafiltration, treatment dose, nutritional support and antibiotic treatment are a vital component of the therapeutic approach in critically ill septic patients [ 88 ].…”

Association between Prolonged Intermittent Renal Replacement Therapy and All-Cause Mortality in COVID-19 Patients Undergoing Invasive Mechanical Ventilation: a Retrospective Cohort Study

“…14,16 However, the benefits of CRRT are still no consistent conclusion in critically ill patients. 17 CRRT significantly reduced the level of IL-6 and decreases hospital mortality rate in pediatric severe sepsis, especially in patients with acute respiratory distress syndrome (ARDS). 18 Besides, a meta-analysis revealed that patients who received CRRT had significantly lower mortality compared to conventional therapy.…”

“…16 The relationship between CRRT and patients' outcome varied in patients with the different disease and was effected by the modalities, anticoagulation, vascular access management, timing of initiation and intensity of CRRT. 17,20,21 To date, no specific treatment has been confirmed to be effective for COVID-19, and supportive treatment remains essential. As far as we know, the effect of CRRT on critically ill patients with COVID-19 has not been reported.…”

Development and Evaluation of Decision Aid for Family Surrogate Decision Makers of Patients with Acute Kidney Injury Requiring Renal Replacement Therapy (RRT) in ICU: A Study Protocol

“…Nowadays, renal replacement therapy (RRT) has been one of the most crucial life supports in ICU so that the incidence of AKI treated with RRT is increasing steeply [3,4]. RRT is regarded as lifesustaining for AKI, with signi cant value in critically ill [5][6][7]. There is no doubt that the decision whether or not to choose RRT should be described as preference-sensitive.…”