When Should Renal Replacement Therapy be Initiated for Acute Kidney Injury?

Abstract

Acute kidney injury (AKI) is now well recognized as an independent risk factor for increased morbidity and mortality particularly when dialysis is needed. Although renal replacement therapy (RRT) has been used in AKI for more than five decades, there is no standard methodology to predict which AKI patients will need dialysis and who will recover renal function without requiring dialysis. The lack of consensus on what parameters should guide the decision to start dialysis has led to a wide variation in dialysis utilization. A contributing factor is the lack of studies in the modern era evaluating the relationship of timing of dialysis initiation and outcomes. Although listed as one of the top priorities in research on AKI, timing of dialysis initiation has not been included as a factor in large, randomized controlled trials in this area. In this review we will discuss the criteria that have been used to define early vs. late initiation in previous studies on dialysis initiation. In addition, we propose a patient-centered approach to define early and late initiation that could serve as framework for managing patients and for future studies in this area.

Patient Selection and Timing of Continuous Renal Replacement Therapy

“…We suggest that the decision to start, maintain and discontinue CRRT should be individualized based on the demand-capacity concept [20]. Our recommendations may serve to develop the best clinical practice and standards of care for use of CRRT in patients with AKI.…”

“…It is assumed that the kidneys have a finite capacity. Consequently, the initiation of RRT should be prompted by the ability of the kidney to meet the demands being placed on them [19,20] . An increasing demand causes an imbalance and may lead to dysfunction in other organs unless corrected quickly.…”

Clinicopathological features and risk factors analysis of IgA nephropathy associated with acute kidney injury

“…Renal replacement treatment (RRT) will also be applied in AKI patients, however, accurate timing and mode of initiation of RRT is still a matter of debate. 27 Standard guidelines for RRT (when to start, which type of RRT to use in what dose and when to stop) are lacked. There were 27 AKI patients received hemodialysis in this study.…”

Role of Technology for the Management of AKI in Critically Ill Patients: From Adoptive Technology to Precision Continuous Renal Replacement Therapy

“…In this manner, progress in the definition of the demands imposed onto the failing kidney and a measure of the capacity of the kidney to respond to the challenge should guide treatment [23][24][25].…”

“…Whenever the demand exceeds the capaci- ty, CRRT is necessary [23] . As critically ill patients continuously vary in their status, assessment of the gap between demand and capacity may have to be continuously reassessed to assist in the decision to start the treatment.…”