Delivering optimal renal replacement therapy to critically ill patients with acute kidney injury

Wald, Ron; Beaubien‐Souligny, William; Chanchlani, Rahul; Clark, Edward G.; Neyra, Javier A.; Ostermann, Marlies; Silver, Samuel A.; Vaara, Suvi T.; Zarbock, Alexander; Bagshaw, Sean M.

doi:10.1007/s00134-022-06851-6

Cited by 36 publications

(24 citation statements)

References 100 publications

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“…Due to their better hemodynamic stability, efficient fluid removal and adequate metabolic control, CRRT and PIRRT represent the primary choices in critically ill patients with AKI [47,48]. Several modalities of RRT are available, each primarily depending on the mechanisms used for solute transport (i.e., diffusion, convection), which can act separately or in combination (Fig.…”

Section: Rationalementioning

confidence: 99%

Regional citrate anticoagulation (RCA) in critically ill patients undergoing renal replacement therapy (RRT): expert opinion from the SIAARTI-SIN joint commission

Pistolesi

Morabito²,

Pota³

et al. 2023

J Anesth Analg Crit Care

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Renal replacement therapies (RRT) are essential to support critically ill patients with severe acute kidney injury (AKI), providing control of solutes, fluid balance and acid–base status. To maintain the patency of the extracorporeal circuit, minimizing downtime periods and blood losses due to filter clotting, an effective anticoagulation strategy is required.Regional citrate anticoagulation (RCA) has been introduced in clinical practice for continuous RRT (CRRT) in the early 1990s and has had a progressively wider acceptance in parallel to the development of simplified systems and safe protocols. Main guidelines on AKI support the use of RCA as the first line anticoagulation strategy during CRRT in patients without contraindications to citrate and regardless of the patient’s bleeding risk.Experts from the SIAARTI-SIN joint commission have prepared this position statement which discusses the use of RCA in different RRT modalities also in combination with other extracorporeal organ support systems. Furthermore, advise is provided on potential limitations to the use of RCA in high-risk patients with particular attention to the need for a rigorous monitoring in complex clinical settings. Finally, the main findings about the prospective of optimization of RRT solutions aimed at preventing electrolyte derangements during RCA are discussed in detail.

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Section: Rationalementioning

confidence: 99%

Regional citrate anticoagulation (RCA) in critically ill patients undergoing renal replacement therapy (RRT): expert opinion from the SIAARTI-SIN joint commission

Pistolesi

Morabito²,

Pota³

et al. 2023

J Anesth Analg Crit Care

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“…Typically, renal replacement therapy is reserved for hemodynamically unstable patients given its lower net ultrafiltration rate, lower rate of osmotic shift, and slower change in extracellular fluid electrolyte concentrations with less impact on resting membrane potentials when compared to intermittent hemodialysis. 123,124 Recent Novel exploratory Studies of cardiac Surgery AKi Prevention…”

Section: Renal Replacement Therapymentioning

confidence: 99%

“…In the general critically ill patient population, indications of renal replacement therapy are focused on solute control (e.g., electrolyte or acid-base imbalances) and volume control to restore euvolemia when patients are no longer diuretic-responsive. 123,124 For timing, data from recently completed clinical trials suggest that "early" initiation of renal replacement therapy in the absence of emergent indications of solute/volume control does not significantly improve mortality outcomes and is associated with more episodes of hypotension and hypophosphatemia. 125 Further, in secondary outcome analysis of the Standard versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial, survivors of AKI-renal replacement therapy had higher risk of being renal replacement therapy-dependent at 90 days when compared to patients randomly assigned to the "delayed" renal replacement therapy initiation strategy.…”

Section: Renal Replacement Therapymentioning

confidence: 99%

Acute Kidney Injury after Cardiac Surgery: Prediction, Prevention, and Management

Cheruku,

Raphael,

Neyra

et al. 2023

Anesthesiology

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Acute kidney injury (AKI) is a common complication in cardiac surgery patients, with a reported incidence of 20 to 30%. The development of AKI is associated with worse short- and long-term mortality, and longer hospital length of stay. The pathogenesis of cardiac surgery–associated AKI is poorly understood but likely involves an interplay between preoperative comorbidities and perioperative stressors. AKI is commonly diagnosed by using increases in serum creatinine or decreased urine output and staged using a standardized definition such as the Kidney Disease Improving Global Outcomes classification. Novel biomarkers under investigation may provide earlier detection and better prediction of AKI, enabling mitigating therapies early in the perioperative period. Recent clinical trials of cardiac surgery patients have demonstrated the benefit of goal-directed oxygen delivery, avoidance of hyperthermic perfusion and specific fluid and medication strategies. This review article highlights both advances and limitations regarding the prevention, prediction, and treatment of cardiac surgery–associated AKI.

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“…This is radically different from the prevailing intermittent therapies, which largely adapted protocols and prescriptions from maintenance dialysis in which solute removal and ultrafiltration are rapidly delivered over a period of 3–4 hours. 2,8 CKRT has become deeply entrenched worldwide, especially in high-income countries, and in particular for critically ill patients with hemodynamic instability or multiorgan dysfunction. 1,2,9 With growing trends in the incidence of AKI, sepsis, and multiorgan dysfunction and the evolving functionality of newer CKRT platforms, the utilization of CKRT is likely to expand further.…”

Section: Introductionmentioning

confidence: 99%

Debate: Intermittent Hemodialysis versus Continuous Kidney Replacement Therapy in the Critically Ill Patient: The Argument for CKRT

Bagshaw

Neyra

Tolwani

et al. 2023

CJASN

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Continuous kidney replacement therapy (CKRT) is well entrenched as one of the dominant KRT modalities in modern critical care practice. Since its introduction four decades ago, there have been considerable innovations in CKRT machines that have improved precision, safety, and simplicity. CKRT is the preferred KRT modality for critically ill patients with hemodynamic instability. Early physical therapy and rehabilitation can be feasibly and safely provided to patients connected to CKRT, thus obviating concerns about immobility. Although randomized clinical trials have not shown a mortality difference when comparing CKRT and intermittent hemodialysis, CKRT allows precision delivery of solute and fluid removal that can be readily adjusted in the face of dynamic circumstances. Accumulated evidence from observational studies, although susceptible to bias, has shown that CKRT, when compared with intermittent hemodialysis, is associated with better short-and long-term kidney recovery and KRT independence. Critical care medicine encompasses a wide range of sick patients, and no single KRT modality is likely to ideally suit every patient in every context and for every condition. The provision of KRT represents a spectrum of modalities to which patients can flexibly transition in response to their evolving condition. As a vital tool for organ support in the intensive care unit, CKRT enables the personalization of KRT to meet the clinical demands of patients during the most severe phases of their illness.

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Delivering optimal renal replacement therapy to critically ill patients with acute kidney injury

Cited by 36 publications

References 100 publications

Regional citrate anticoagulation (RCA) in critically ill patients undergoing renal replacement therapy (RRT): expert opinion from the SIAARTI-SIN joint commission

Regional citrate anticoagulation (RCA) in critically ill patients undergoing renal replacement therapy (RRT): expert opinion from the SIAARTI-SIN joint commission

Acute Kidney Injury after Cardiac Surgery: Prediction, Prevention, and Management

Debate: Intermittent Hemodialysis versus Continuous Kidney Replacement Therapy in the Critically Ill Patient: The Argument for CKRT

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