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KEY POINTS

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  • Indications for the initiation of renal replacement therapy (RRT) remain reactive, often waiting until potentially life-threatening complications/thresholds have been met.

  • The goal of renal replacement therapy should be to provide “renal support” to facilitate the other aspects of care of the critically ill patient (fluid balance, nutritional support, etc).

  • Retrospective and observational studies suggest that the early initiation of RRT may improve patient outcomes; however, definitive randomized, controlled trials have yet to be performed.

  • In the setting of acute kidney injury (AKI), no specific RRT modality (intermittent, continuous, or peritoneal) provides a mortality benefit over another. However, certain clinical scenarios (eg, hepatic failure, increased intracranial pressure) may mandate a specific modality.

  • In the setting AKI, randomized controlled trials have demonstrated that a minimum dose of 25 mL/kg/h of continuous renal replacement therapy (CRRT) be delivered in order to improve patient survival. Data on dosing of intermittent dialysis suggest prescription of a minimum of three treatments per week.

  • No singular method of systemic or regional anticoagulation, in the setting of AKI requiring renal replacement therapy, has demonstrated superiority. Several options including heparin, citrate, and no anticoagulation remain extremely common and each has their own risks and benefits.

  • In the setting of AKI requiring RRT, nutritional support consistent with the current ESPEN guidelines and monitoring of parameters of nutritional status in critically ill patients are appropriate.

  • Depending on the modality of RRT (intermittent, continuous, or peritoneal), dosing strategies for medications (including antimicrobials) differ significantly.

  • Adherence to dosing guidelines is critical to ensure that the targeted therapeutic dose is delivered in the setting of AKI and RRT, as inappropriate dosing has a significant impact on patient outcomes and increases the risk of mortality.

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Despite advances in medicine and critical care, the nephrology community has yet to develop a consistent, proven intervention to predictably prevent or hasten the recovery of all forms of acute kidney injury (AKI), including its most severe form, acute tubular necrosis (ATN). Thus, care for the patient with AKI is focused on supportive measures including treatment of the underlying disease state and, when needed, renal replacement therapy (RRT). While advances in nephrology have not identified a consistent therapy for the prevention or improved recovery for AKI, there have been considerable advances in the field of RRT.

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RRT: AN INTRODUCTION

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RRT, in this setting, refers to the use of extracorporeal support to remove solutes and water. The current available modalities of RRT are intermittent hemodialysis (IHD), peritoneal dialysis (PD), and the various blood-based modalities of continuous renal replacement therapy (CRRT). CRRT modalities include continuous venovenous hemodialysis (CVVHD), continuous venovenous hemofiltration (CVVH), and combination therapies, that is continuous hemodiafiltration (CVVHDF). The advances in technology with readily available large bore temporary and tunneled venous catheters and blood pumps have made the use of arteriovenous circuits, in the form of continuous arteriovenous hemofiltration/hemodialysis (CAVH/CAVHD) essentially obsolete.

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The general principles underlying these various ...

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