Renal Replacement Therapy in the Critical Care Setting

Abstract

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.

Factors Associated with In-Hospital Mortality after Continuous Renal Replacement Therapy for Critically Ill Patients: A Systematic Review and Meta-Analysis

“…The prevalence of AKI has been reported for approximately 30-60% critically ill patients in intensive care units (ICUs) [4,5]. Therefore, renal replacement therapy is vital for critically ill patients with AKI to provide supportive management in critical care settings aimed at speeding up renal recovery and preventing adverse events [6]. The first choice for patients with AKI is continuous renal replacement therapy (CRRT), as most critically ill patients are hemodynamically un-stable [7,8].…”

Kidney injury in COVID-19

“…Many of these patients required it due to AKI with severe electrolyte derangements and/or volume overload intending to achieve net even or negative fluid balance. The timing of initiating CRRT varies amongst centres, however, two major randomised control trials over the last decade showed a delayed strategy of either absolute indications developing or AKI KDIGO stage 3 for more than 48 h compared to an early strategy of RRT within 6-12 h of AKI KDIGO stage 3 that had no difference in mortality, ICU-free days, ventilator-free days and vasopressor-free days[ 126 - 129 ]. Many patients did not require CRRT in the delayed group due to recovery of native renal function.…”

“…CRRT timing should be based on an individual patient’s physiological reserve. This depends on age, cardiovascular risk factors, pulmonary comorbidities, baseline renal function and the trend of inflammatory and renal injury markers[ 129 ]. A delayed strategy of waiting for 48–72 h after progressing to AKI KDIGO 3 or until an absolute indication that arises may apply to most COVID-19 patients with septic shock[ 129 ].…”

“…This depends on age, cardiovascular risk factors, pulmonary comorbidities, baseline renal function and the trend of inflammatory and renal injury markers[ 129 ]. A delayed strategy of waiting for 48–72 h after progressing to AKI KDIGO 3 or until an absolute indication that arises may apply to most COVID-19 patients with septic shock[ 129 ]. CRRT can be applied earlier in ARDS patients, who despite optimum volume management with diuretics are not able to attain an early cumulative net even or negative fluid balance.…”

Role of continuous renal replacement therapy in severe rhabdomyolysis with multiple organ failure due to methandriol abuse

“…Studije u budućnosti pokazat će njihovu pred nost naspram konvencionalnih metoda i utjecaj na konačno preživljenje. 7 U ovom prikazu bolesnika kontinuirane metode bu brežnoga nadomjesnog liječenja pružile su učinkovitu metodu pristupa, zbrinjavanja i stabilizacije akutnoga bubrežnog zatajenja u sklopu multiorganskog urušaja različite etiogeneze.…”