Criteria for Continuous Kidney Replacement Therapy Cessation in ICU Patients

Abstract

Introduction: In intensive care unit (ICU) patients with acute kidney injury, specific recommendations to guide the decision to cease continuous kidney replacement therapy (CKRT) are lacking.

Methods: We performed a survey to identify criteria currently used to cease CKRT in real-life clinical practice in the Netherlands. We used an online questionnaire with multiple choice questions designed with web-based software from SurveyMonkey.

Results: We received 169 completed questionnaires from intensivists (n = 126) and nephrologists (n = 43). Essential determinants for the cessation of CKRT were a spontaneously increasing diuresis (indicated by 92% of the respondents), absence of fluid overload (indicated by 88% of the respondents), and improvement in creatinine clearance (indicated by 61% of the respondents; intensivists 56%; nephrologists 77%, p = 0.03). Most often mentioned cut-off values used for increase in diuresis were 0.25 and 0.5 mL/kg/h (35% and 33%, respectively). Actual CKRT cessation was often postponed until the filter clots or until circuit disconnection is needed because of patient transport for diagnostic or intervention procedures (indicated by 58% of the respondents). Expected discharge from the ICU was the most frequently reported determinant to switch from CKRT to hemodialysis (indicated by 67% of the respondents).

Conclusions: CKRT cessation in clinical practice is mostly based on spontaneously increasing diuresis, absence of fluid overload, and improvement in creatinine clearance and is often delayed until filter clotting or disconnection of the circuit because of logistic reasons.

Keywords: Acute kidney injury; Continuous kidney replacement therapy; Continuous renal replacement therapy; Intensive care; Survey.

Fig. 1

Flow diagram of respondent selection. KRT, kidney replacement therapy; CKRT, continuous kidney replacement therapy.

Fig. 2

Reported amount of diuresis necessary to decide to cease continuous kidney replacement therapy (CKRT). Shown values are percentages of the total number of intensivists (114/126) and nephrologists (42/43) who indicated to look at diuresis as a factor in the decision to cease CKRT. Not all respondents specified the necessary quantity of diuresis before CKRT ceasing. 32 (31%) intensivists and 20 (48%) nephrologists indicated to look at the amount of diuresis per 24 h (prespecified options in the questionnaire: >400 mL and >1,000 mL). Based on a mean body weight of 72 kg for women and 85 kg for men in the Netherlands^a and the assumption of an equal incidence of CKRT in both sexes the reported amount of diuresis per 24 h was converted to an amount per kg/h. Reported necessary diuresis before CKRT cessation did not differ between intensivists and nephrologists. ^aSource: Statistics Netherlands (CBS) 2018.

Fig. 3

Reported amount of diuresis necessary to decide to cease continuous kidney replacement therapy (CKRT) after furosemide administration. Shown values are percentages of the total number of intensivists (61/126) and nephrologists (23/43) who indicated to look at diuresis after administration of furosemide as a factor in the decision to cease CKRT. Not all respondents specified the necessary quantity of diuresis after furosemide administration before CKRT ceasing. Reported necessary diuresis after furosemide administration for ceasing CKRT did not differ between intensivists and nephrologists.

Fig. 4

Reported creatinine clearance necessary to cease continuous kidney replacement therapy (CKRT). Shown values are percentages of the total number of intensivists (70/126) and nephrologists (33/43) who indicated to take creatinine clearance into account as a factor in the decision to cease CKRT. Reported necessary creatinine clearance needed for ceasing CKRT differed significantly between intensivists and nephrologists.

Fig. 5

Estimated need for continuous kidney replacement therapy (CKRT) re-initiation within 72 hours after cessation of CKRT. Shown values are percentages of the total number of intensivists (126) and nephrologists (43). Data on the estimated reinitiation rate was not reported by 5 intensivists.