The future of critical care: renal support in 2027

Abstract

Since its inception four decades ago, both the clinical and technologic aspects of continuous renal replacement therapy (CRRT) have evolved substantially. Devices now specifically designed for critically ill patients with acute kidney injury are widely available and the clinical challenges associated with treating this complex patient population continue to be addressed. However, several important questions remain unanswered, leaving doubts in the minds of many clinicians about therapy prescription/delivery and patient management. Specifically, questions surrounding therapy dosing, timing of initiation and termination, fluid management, anticoagulation, drug dosing, and data analytics may lead to inconsistent delivery of CRRT and even reluctance to prescribe it. In this review, we discuss current limitations of CRRT and potential solutions over the next decade from both a patient management and a technology perspective. We also address the issue of sustainability for CRRT and related therapies beyond 2027 and raise several points for consideration.

ACUsmart Continuous Renal Replacement Therapy Platform: Multicenter Pilot Study for Technical and Clinical Assessment (A.M.P. Study)

“…In addition to safety features of the therapy, other aspects have become important in further developments including smooth treatment performance, easy usability, and consequent efficient use of resources, application of a standardized nomenclature [16][17][18], and possibly, a biofeedback-controlled treatment using signals from patients and machines to drive treatment parameters. In literature, there is already some idea of how these devices will evolve from today to the next 10 years [19].…”

Progress in the Development and Challenges for the Use of Artificial Kidneys and Wearable Dialysis Devices

“…Thus, continuous renal replacement therapies (CRRT) are the choice in hemodynamically instable patients, because they allow a slow and constant fluid removal, targeted to match the plasma refill rate, to ensure patient survival and renal functional recovery. These techniques of renal substitution therapy have allowed the conceptual shift from renal “replacement” to renal “support” therapies [8], and the term “dynamic CRRT” has been proposed to show that any treatment has to be dynamic and adaptable to the constantly changing clinical status of critically ill patients [9]. …”

“…Currently, the technical limitations of the equipment for supporting CRRT include the software for hemodynamic optimization, the need for a continuous evaluation of the efficiency of solute and fluid removal, and the management of big amounts of data [8]. The continuity of the management of AKI should include biofeedback for dialysis prescription, but we have to bear in mind that the speed of this feedback will depend on the frequency of data acquisition and evaluation.…”

Introductory Chapter: Principles and Methods of Acute Therapies

“…Despite the general safety and valuable advantages, CRRT has some limitations. These include the requirement of a large-bore central vascular access (a risk source of infection), hypotension (decreased organ perfusion), continuous anticoagulation (inappropriate doses or inadequate control of anticoagulants may lead to bleeding, which is associated with a decrease in hemoglobin level and/or drop in blood pressure and possible need of blood transfusion, or clot formation that is associated with short circuit life, interruption of prescribed dose, inadequate therapy, and increased cost), electrolyte imbalance (potassium, phosphorus, and magnesium), drug removal (e.g., antibiotics), and immobilization of the patient for prolonged periods [9].…”