Renal replacement therapy in acute kidney injury: controversy and consensus

Abstract

Renal replacement therapies (RRTs) represent a cornerstone in the management of severe acute kidney injury. This area of intensive care and nephrology has undergone significant improvement and evolution in recent years. Continuous RRTs have been a major focus of new technological and treatment strategies. RRT is being used increasingly in the intensive care unit, not only for renal indications but also for other organ-supportive strategies. Several aspects related to RRT are now well established, but others remain controversial. In this review, we review the available RRT modalities, covering technical and clinical aspects. We discuss several controversial issues, provide some practical recommendations, and where possible suggest a research agenda for the future.

Blood purification in intensive care patients with multiple organ dysfunction syndrome and sepsis after cardiac surgery

“…[6] The goal of extracorporeal blood purification in the ICU today should be the treatment of MODS considering the pathophysiological aspects of it rather than the classical RRT in AKI. [7,8] The choice of the optimal blood purification modality is based on the ability to correct water-electrolyte and metabolic imbalances and to decrease the manifestations of endo-and exotoxicosis, and other homeostatic disorders, thereby improving survival of critically ill patients. Multiple organ support therapy is an effective clinical approach.…”

“…[5] We also think that blood purification's positive effects are implemented by filtration of interstitial fluid excess and reduction of myocardial and pulmonary edema. [8] The effectiveness of any blood purification method in cardiosurgery patients depends on the adequate correction of electrolyte (hyperkalemia, hyper-and/or hyponatremia) and metabolic (lactatemia, acidosis, alkalosis) disorders and azotemia. Hyperkalemia is caused by acute kidney injury, catabolism, rhabdomyolysis and reperfusion after crash syndrome, hemolysis and disseminated intravascular coagulation.…”

“…Its elimination of medium-molecular depressive factors, which are elevated in MODS and sepsis, [2,8] and correction of hyperkalemia and azotemia prevent the development of immune paralysis and uremic polyserositis. During extracorporeal procedures, it is possible to normalize body temperature and temperature balance as a whole.…”

Intermittent Hemodialysis Low Intensity vs. on Line Hemodiafiltration in Critically Ill Patients with Sepsis and Acute Kidney Injury. Choosing the Best Treatment in a Developing Country

“…Also there are controversial results when comparing mortality rates between intermittent haemodialysis low intensity (IHD-LI) and intermittent hemodialysis high intensity (IHD-HI) and finally against continuous veno venous hemofiltration (CVVH) [20][21][22][23][24][25]. In a multicenter, randomized, controlled study was compared the best therapeutic haemodialysis scheme, the aim was to measure mortality at 60 days, results didn´t find advantages between intense haemodialysis (six sessions a week HD) versus IHD-LI (three times a week for a Kt/V target of 1.2 to 1.4 per session).…”

Timing of renal replacement therapy in critically ill patients with acute kidney injury

“…However, a number of issues affecting the optimal use of this primarily supportive technique still remain unresolved (3). The most important question now increasingly being asked is at what point and at which stage to initiate renal replacement therapy in critically ill patients with evolving acute kidney injury.…”