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Review
. 2023 Jan 1;18(1):113-120.
doi: 10.2215/CJN.05450522. Epub 2022 Sep 13.

Indications for and Timing of Initiation of KRT

Marlies Ostermann  1 , Sean M Bagshaw  2 , Nuttha Lumlertgul  1   3   4 , Ron Wald  5   6
Affiliations
Review

Indications for and Timing of Initiation of KRT

Marlies Ostermann et al. Clin J Am Soc Nephrol. .

Abstract

KRT is considered for patients with severe AKI and associated complications. The exact indications for initiating KRT have been debated for decades. There is a general consensus that KRT should be considered in patients with AKI and medically refractory complications ("urgent indications"). "Relative indications" are more common but defined with less precision. In this review, we summarize the latest evidence from recent landmark clinical trials, discuss strategies to anticipate the need for KRT in individual patients, and propose an algorithm for decision making. We emphasize that the decision to consider KRT should be made in conjunction with other forms of organ support therapies and important nonkidney factors, including the patient's preferences and overall goals of care. We also suggest future research to differentiate patients who benefit from timely initiation of KRT from those with imminent recovery of kidney function. Until then, efforts are needed to optimize the initiation and delivery of KRT in routine clinical practice, to minimize nonessential variation, and to ensure that patients with persistent AKI or progressive organ failure affected by AKI receive KRT in a timely manner.

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Conflict of interest statement

S.M. Bagshaw is supported by a Canada Research Chair in Critical Care Outcomes and Systems Evaluation; reports consultancy agreements with Baxter, BioPorto, and Novartis; reports research funding from Baxter; reports honoraria from Baxter; reports fees from Baxter for scientific advisory and speaking; reports fees from BioPorto for scientific advisory and clinical adjudication; reports fees from Novartis for scientific advisory; serves as an associate editor for Critical Care and a Data and Safety Monitoring Board (DSMB) member for the The Investigation of Serial studies to Predict Your Therapeutic Response with Imaging And moLecular Analysis in COVID (I-SPY-COVID) trial; and serves on a speakers bureau for Baxter. M. Ostermann reports consultancy agreements with Biomerieux and NxStage; reports research funding from Baxter, Biomerieux, Fresenius Medical Care, and La Jolla Pharma; reports speaker honoraria from Baxter, Biomerieux, and Fresenius Medical; serves on the editorial boards of Blood Purification, Critical Care, Intensive Care Medicine, and Nephrology Dialysis Transplantation; and serves as a member of the Executive Committee of the European Society of Intensive Care Medicine and a member of the Executive Committee of the Intensive Care Society UK. R. Wald reports unrestricted research funding from Baxter and consulting fees from Lilly; serves on the editorial boards of CJASN, Kidney360, and Kidney Medicine; and is a contributor to UpToDate. All remaining authors have nothing to disclose.

Figures

Figure 1
Figure 1
Factors affecting the initiation of KRT in the intensive care unit (ICU).
Figure 2
Figure 2
Algorithm to guide KRT initiation.
See this image and copyright information in PMC

References

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    1. Bagshaw SM, Darmon M, Ostermann M, Finkelstein FO, Wald R, Tolwani AJ, Goldstein SL, Gattas DJ, Uchino S, Hoste EA, Gaudry S: Current state of the art for renal replacement therapy in critically ill patients with acute kidney injury. Intensive Care Med 43: 841–854, 2017 - PubMed
    1. Ostermann M, Dickie H, Barrett NA: Renal replacement therapy in critically ill patients with acute kidney injury--When to start. Nephrol Dial Transplant 27: 2242–2248, 2012 - PubMed
    1. Libório AB, Leite TT, Neves FM, Teles F, Bezerra CT: AKI complications in critically ill patients: Association with mortality rates and RRT. Clin J Am Soc Nephrol 10: 21–28, 2015 - PMC - PubMed
    1. Ostermann M, Straaten HM, Forni LG: Fluid overload and acute kidney injury: Cause or consequence? Crit Care 19: 443, 2015 - PMC - PubMed