Effects of Renal Replacement Therapy on Renal Recovery after Acute Kidney Injury

Abstract

Recovery of kidney function following an episode of acute kidney injury (AKI) is now acknowledged as a vital patient-centered outcome with clear health economic implications. In approximately 5-8% of critically ill patients with more severe forms of AKI, support with renal replacement therapy (RRT) is provided. Recent data have suggested that rates of RRT utilization in AKI are increasing. Despite advances in our understanding of how best to prescribe acute RRT in critically ill patients with AKI, additional aspects remain uncertain, predisposing to suboptimal delivery and variation in practice. Importantly, if, when, how, and by what principles we apply acute RRT for AKI are all treatment decision-related factors that are modifiable and may interact with recovery of kidney function. Limited data, mostly from observational studies and secondary analyses, have explored the specific association between acute RRT and recovery. Available data are not able to clarify whether providing any RRT in otherwise eligible patients with AKI impacts recovery. They are also unable to inform whether the timing or circumstance under which RRT is started impacts recovery. No studies have evaluated whether there is an optimal time to start RRT to maximize the probability of recovery. Accumulated evidence, mostly derived from observational studies, suggests initial therapy in critically ill patients with AKI with continuous RRT, compared with intermittent modalities, improves the probability of recovery to dialysis independence. Evidence from high-quality randomized trials failed to show any association between delivered dose intensity of RRT and recovery. The use of biocompatible membranes for acute RRT may improve recovery in AKI; however, data are inconsistent. Limited data have evaluated the impact of membrane flux properties on recovery. Preliminary data have suggested that circuit anticoagulation with citrate, which results in a reduction in membrane-induced oxidative stress and leukocyte activation, may be associated with improved recovery; however, further corroborative data are needed. Additional evidence, ideally from randomized trials, is clearly needed to inform best practice in the delivery of acute RRT to optimize probability of recovery of kidney function for survivors of AKI.

Renal replacement therapy is independently associated with a lower risk of death in patients with severe acute kidney injury treated with targeted temperature management after out-of-hospital cardiac arrest

“…This may have been due to the high rate of shock after ROSC. These results are compatible with current standards because CRRT is recommended as the initial RRT modality [21]. A higher frequency of bleeding in the RRT group may have been caused by complications during the insertion of the dual-lumen haemodialysis catheter ( Table 1).…”

Predicting Renal Recovery After Dialysis-Requiring Acute Kidney Injury

“…Another limitation of our study was that not all clinical details related to the AKI-D hospitalizations were available. We were missing information regarding etiology of preexisting CKD, indication for RRT initiation, initial RRT modality (e.g., intermittent vs. continuous therapy), physiologic variables at time of RRT initiation including APACHE score and urine output, inpatient medication use, and setting of AKI (e.g., sepsis or postsurgery); however, there is no definitive evidence that dialysis duration,12, 56 dialysis dose,57, 58 choice of dialysis membrane, 59 RRT modality,9, 12, 56, 59, 60, 61, 62, 63, 64 timing of dialysis initiation,65, 66, 67, 68 or medications such as diuretics69, 70, 71 are associated with chances of recovery. Although the specific etiology of AKI-D was also unavailable in our dataset, prior chart review of KPNC medical records by a board-certified nephrologist of similar cases showed that almost all were due to acute tubular necrosis 13, 15.…”

Renal Function Outcome Prognosis in Septic and Non-septic Acute Kidney Injury Patients

“…Recent data have suggested that rates of RRT utilization in AKI are increasing ( 17 ). However, only 19% of all AKI patients included in our study were treated with RRT, which is similar with prevalence (12%) found in recent survey conducted in 10 Italian ICU ( 18 ).…”