Abstract
Acute kidney injury (AKI) is a common complication in critically ill patients with an incidence of up to 50% in intensive care patients. The mortality of patients with AKI requiring dialysis in the intensive care unit is up to 50%, especially in the context of sepsis. Different approaches have been undertaken to reduce this high mortality by changing modalities and techniques of renal replacement therapy: an early versus a late start of dialysis, high versus low dialysate flows, intermittent versus continuous dialysis, anticoagulation with citrate or heparin, the use of adsorber or special filters in case of sepsis. Although in smaller studies some of these approaches seemed to have a positive impact on the reduction of mortality, in larger studies these effects could not been reproduced. This raises the question of whether there exists any impact of renal replacement therapy on mortality in critically ill patients—beyond an undeniable impact on uremia, hyperkalemia and/or hypervolemia. Indeed, this is one of the essential challenges of a nephrologist within an interdisciplinary intensive care team: according to the individual situation of a critically ill patient the main indication of dialysis has to be identified and all parameters of dialysis have to be individually chosen with respect to the patient’s situation and targeting the main dialysis indication. Such an interdisciplinary and individual approach would probably be able to reduce mortality in critically ill patients with dialysis requiring AKI.
Highlights
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Dialysis became a common treatment of the major complications of Acute kidney injury (AKI), hypervolemia, hyperkalemia and uremia, resulting in reduced mortality
Some studies reported that citrate anticoagulation could possibly have a positive influence on mortality in sepsis and multiple organ failure compared to heparin [14], based on the idea that citrate could reduce calcium-dependent inflammatory processes with a positive influence on the outcome
Summary
Acute kidney injury (AKI) is a common complication in critically ill patients. Severe AKI leads to three classical life-threatening complications which may occur alone or in combination: hypervolemia, hyperkalemia and uremia. Dialysis became a common treatment of the major complications of AKI, hypervolemia, hyperkalemia and uremia, resulting in reduced mortality. Anticoagulation with heparin is targeted on the technical needs of effective dialysis This increases the risk of bleeding in critically ill patients, especially in the context of coagulation disorders or surgery interventions. Some studies reported that citrate anticoagulation could possibly have a positive influence on mortality in sepsis and multiple organ failure compared to heparin [14], based on the idea that citrate could reduce calcium-dependent inflammatory processes with a positive influence on the outcome. Plasmapheresis and liver replacement therapy are essential and indispensable methods—even though not often used compared to dialysis These methods are used in specialized centers with interdisciplinary intensive care units. Plasmapheresis does not play a major role in everyday clinical practice and is only used in exceptional cases in the critically ill—with the exception of neurological indications such as severe myasthenia or Guillain Barré syndrome requiring intensive care [26]
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