When and why to start continuous renal replacement therapy in critically ill patients with acute kidney injury

Abstract

Acute kidney injury (AKI) is a common condition in critically ill patients, and may contribute to significant medical, social, and economic consequences, including death. Although there have been advances in medical technology, including continuous renal replacement therapy (CRRT), the mortality rate of AKI is high, and there is no fundamental treatment that can reverse disease progression. The decision to implement CRRT is often subjective and based primarily on the clinician's judgment without consistent and concrete guidelines or protocols regarding when to initiate and discontinue CRRT and how to manage complications. Recently, several randomized controlled trials addressing the initiation of renal replacement therapy in critically ill patients with AKI have been completed, but clinical application of the findings is limited by the heterogeneity of the objectives and research designs. In this review, the advantages and disadvantages of CRRT initiation, clinical guideline recommendations, and the results of currently published clinical trials and meta-analyses are summarized to guide patient care and identify future research priorities.

Keywords: Acute kidney injury; Continuous renal replacement therapy; Guideline; Meta-analysis; Randomized controlled trial.

Figure 1.. In the absence of absolute indications, predicting the prognosis of critically ill AKI patients undergoing early initiation of RRT is complex.

. Reproduced from the article of Prowle and Davenport (Kidney Int 2015;88:670–673) [25] with the permission from Elsevier. AKI, acute kidney injury; RRT, renal replacement therapy.

Figure 2.. Clinical decision tree for initiation of RRT in critically ill patients with AKI.

Reproduced from the article of Ostermann et al. (Contrib Nephrol 2016;187:106-120) [22] with the permission from S. Karger AG. AKI, acute kidney injury; RRT, renal replacement therapy.