Abstract
Critically ill patients whose course is complicated by acute kidney injury often receive renal replacement therapy (RRT). For these patients, initiation of RRT results in a considerable escalation in both the complexity and associated cost of care. While RRT is extensively used in clinical practice, there remains uncertainty about the ideal circumstances of when to initiate RRT and for what indications. The process of deciding when to initiate RRT in critically ill patients is complex and is influenced by numerous factors, including patient-specific and clinician-specific factors and those related to local organizational/logistical issues. Studies have shown marked variation between clinicians, and across institutions and countries. As a consequence, analysis of ideal circumstances under which to initiate RRT is challenging. Recognizing this limitation, we review the available data and propose a clinical algorithm to aid in the decision for RRT initiation in critically ill adult patients. The algorithm incorporates several patient-specific factors, based on evidence when available, that may decisively influence when to initiate RRT. The objective of this algorithm is to provide a starting point to guide clinicians on when to initiate RRT in critically ill adult patients. In addition, the proposed algorithm is intended to provide a foundation for prospective evaluation and the development of a broad consensus on when to initiate RRT in critically ill patients.
Highlights
Acute kidney injury (AKI) is a well-recognized complication of critical illness with an important impact on morbidity, mortality and health resource utilization [1,2,3,4,5]
While large prospective studies are urgently needed, the currently available data would indicate a potential benefit associated with earlier initiation of Renal replacement therapy (RRT) for those patients where RRT is likely to be needed in terms of both survival and recovery of kidney function [12,15]
Earlier initiation of RRT has the potential to expose patients to this therapy who may have otherwise spontaneously recovered kidney function and/or survived without having received it. This issue, is complicated by a paucity of data in critically ill patients with AKI investigating factors that reliably predict whether recovery of kidney function will occur and whether this can be modified by earlier RRT initiation
Summary
Acute kidney injury (AKI) is a well-recognized complication of critical illness with an important impact on morbidity, mortality and health resource utilization [1,2,3,4,5]. We adapt the terminology proposed by the Acute Kidney Injury Network (AKIN): ‘illness trajectory’ refers to the pace of clinical evolution of the patient, and AKI ‘trend’ refers to the rate of clinical and/or biochemical changes (including urea and creatinine) [16] The objective of this algorithm is to provide a starting point to guide clinicians on when to consider use of RRT in adult critically ill patients. This issue, is complicated by a paucity of data in critically ill patients with AKI investigating factors that reliably predict whether recovery of kidney function will occur (that is, partial recovery or RRT-free) and whether this can be modified by earlier RRT initiation We believe this is a research priority. As more definitive data become available, incorporation of these biomarkers into the decision-making process is likely
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