Anticipation of recovery of native renal function and liberation from renal replacement therapy in critically ill patients with severe acute kidney injury

Abstract

Background Renal replacement therapy (RRT) is used to manage critically ill patients with severe acute kidney injury (AKI-D), and it is undoubtedly life-sustaining for most patients. However, the prolonged unnecessary use of these techniques may be harmful. At present, no consensus guidelines provide specific recommendations for clinicians on when (optimal timing of discontinuation) and how (liberation or weaning) to stop RRT in intensive care unit (ICU) patients with recovering native kidney function. Methods and results Numerous variables such as clinical parameters, classical surrogate markers for glomerular filtration rate, novel biomarkers of kidney function and damage, and new imaging techniques in AKI-D have been described to predict successful discontinuation of RRT. Most available studies are limited by study design, heterogeneity of variable assessment and thresholds of biomarkers, and lack of prospective validation. At present, the decision on discontinuation of RRT in ICU patients is based on three clinical scenarios: (a) intrinsic kidney function (defined as spontaneous urine output > 500 ml/24 h, timed creatinine clearance > 15 to 20 ml/min) has adequately improved to match the demands and continued RRT is no longer consistent with goals of care (transition to intermittent RRT); (b) the acute illness that prompted RRT has improved; (c) the clinical practice of switching haemodynamic stable patients with persistent AKI-D from continuous RRTs to intermittent RRTs is variable, but de-escalation of RRT (frequency, dose) may facilitate mobilization and discharge of ICU patients. Conclusions The predictive ability of novel kidney biomarkers, surrogate markers of kidney function, and direct measurements of kidney function should be evaluated in future studies.

Failing kidneys: renal replacement therapies in the ICU

“…16 Clinically, this is often interpreted using variable application of the measures (1) adequate UOP>1000 mL/day or UOP>2000 mL/day in setting of diuretics, (2) spontaneous decrease in serum creatinine, (3) absence of any AKI KDIGO stages and ( 4) not requiring RRT in the past 7 days. 24 ICU patients on CRRT and PIRRT should be transitioned to IHD if they continue to require RRT.…”