Indian Journal of Nephrology Home 

CHAPTER 19
[Download PDF]
Year : 2020  |  Volume : 30  |  Issue : 7  |  Page : 77--78

Renal replacement therapy in intensive care unit for acute kidney injury

 

Correspondence Address:

How to cite this article:
. Renal replacement therapy in intensive care unit for acute kidney injury.Indian J Nephrol 2020;30:77-78

How to cite this URL:
. Renal replacement therapy in intensive care unit for acute kidney injury. Indian J Nephrol [serial online] 2020 [cited 2020 Sep 26 ];30:77-78
Available from: http://www.indianjnephrol.org/text.asp?2020/30/7/77/289823

Full Text



AKI occurs in about 30%–50% of patients admitted to the intensive care unit (ICU), about a quarter of whom may need dialysis. AKI patients in ICU differ from ESRD patients on HD in the following ways: (1) the rate as well as the amount of nitrogenous waste products generated is higher due to increased catabolic rate, (2) cardiovascular instability is more likely and (3) there is an increased need for fluid removal and correction of metabolic acidosis. The application of RRT in ICU for AKI should take in to account these factors.

 Choice of Renal Replacement Therapy in Intensive Care Unit



We recommend that all forms of RRT (HD, SLED, CRRT or peritoneal dialysis [PD]) may be used in ICU.We suggest that adult patients who are septic and hypercatabolic should be treated with HD, SLED or CRRT in preference over PD.We recommend use of CRRT or SLED in patients with hypotension or who require vasopressor drugs.We recommend use of CRRT for patients with increased intracranial pressure such as neurosurgical patients and fulminant hepatic failure. In case CRRT is not available, SLED or PD may be used instead, in such circumstances.The duration and frequency of SLED should be determined by the requirement of UF and need for solute removal.We recommend choosing the modality of CRRT: Continuous venovenous hemofiltration (HF) (CVVH), continuous veno-venous HD (CVVHD), or a combination (continuous venovenous HDF [CVVHDF]), according to clinician expertise and availability of resources.We recommend not using AV techniques of CRRT, as efficacy and safety monitoring may be inadequate.We recommend the use of dedicated machines with full safety features for CRRT.We recommend use of machines capable of low dialysate flow rates (£ 300 ml/min) for SLED.We recommend use of HD or SLED on alternate days. However, more frequent HD or SLED may be done, if metabolic and fluid management demands are not met.

 Vascular Access for Dialysis in Intensive Care Unit



We recommend the IJV as the preferred vascular access.The vascular access should be a dedicated cannula of a minimum of 12F in adults, and should not be used for administering drugs or TPN or measurement of central venous pressure.

 Dialysate and Replacement Fluids



We recommend using bicarbonate-based dialysate for intermittent HD (IHD) and SLEDWe recommend that bicarbonate based dialysate may be preferred over lactate-based dialysate in CRRTWe recommend not using lactate-based dialysate for CRRT in patients with liver failure and cachectic patients with poor muscle massWe recommend use of isotonic bicarbonate-based fluid as replacement fluid in CRRT. Alternately, lactate based or saline based isotonic fluids may be for replacement in case isotonic bicarbonate fluids are not availableWe recommend adjusting the potassium concentrate in the dialysate fluid and replacement fluid between 0 and 4 mmol/L depending on the individual need. [Table 1] lists the available fluids which can be used for continuous renal replacement therapy.{Table 1}

 Dialyzers and Hemofilters



We suggest that standard IHD and SLED may be carried out with low flux dialyzersWe recommend use of dialyzers made of biocompatible materialsWe recommend use of CRRT sets that are compatible with the machineThe UF rate should be adjusted for individual patientsThe blood flow should be set so that the filtration fraction is <20% of the blood flow (especially applicable to HF and HDF).

 Anticoagulation



Unless contraindicated, we recommend unfractionated heparin as the anticoagulant of choice during IHD and CRRTWe recommend heparin as a continuous infusion inpatients on CRRT with aPTT monitoring every 4–6 h. After an initial loading dose of 1500–2000 units, an infusion of 250–500 U/h may be initiated and adjusted according to the aPTT reportsWe recommend the aPTT should be maintained at between 45 and 60 s or around 1.5 times the control valueWe suggest that HD and SLED can be carried out without any anticoagulation in patients with coagulation abnormality or who are at increased risk of bleedingWe suggest that regional citrate anticoagulation may be used for CRRT, where expertise to initiate and monitor such a therapy is available.

 Initiation and Prescription of Renal Replacement Therapy



We recommend that RRT should be initiated emergently when life threatening conditions such as electrolyte disturbances, pulmonary edema or acid base disturbance that do not respond to medical management existWe recommend initiation of RRT electively in AKI, when metabolic and fluid demands far exceed the capacity of the kidney to handle themWe recommend a Kt/V of ≥1.2 per se ssion during HD and SLEDWe suggest increasing the frequency of dialysis to achieve appropriate fluid balance or acidosis, hyperkalemia correction or for urea clearance, if extremely hypercatabolicWe recommend that SLED may be performed thrice a week with 6–12 h sessions. More frequent or longer sessions may be determined by the need for UF and acidosis correction rather than enhanced urea clearanceWe recommend dialysate flow rate of 100–300 ml/min and BFR of 100–150 ml/min during SLEDFor CRRT, we recommend a total effluent (dialysate plus UF) rate of 20–25 ml/kg/h. However, the dose may be dynamic and adjusted to the metabolic demands of the individual patient. A higher dose may be needed in extremely catabolic or septic patientsWe recommend combination of diffusion and convection for CRRT, the proportion of which may vary.

 Goals of Renal Replacement Therapy



We recommend periodic monitoring of blood urea, serum creatinine, serum electrolytes, divalent ions and arterial or venous blood gases while on CRRT. The frequency of tests may be based on the individual needsWe recommend the use of standardized protocols to deliver CRRTWe recommend achieving volume status as close to euvolemia as possibleWe recommend correction of acidosis to maintain pH ≥7.2We recommend maintaining serum electrolyte and divalent ion concentrations within reasonably normal limits (sodium: 130–148 mmol/L, potassium: 3.5–5.5 mmol/L, ionised calcium 1–1.3 mmol/L, and serum phosphorus: 2.5–4.5 mg/dL).

 Transition of Renal Replacement Therapy Modality and Stopping Renal Replacement Therapy



The different modalities of RRT in AKI should be view as complimentary and a switch from one modality of RRT to another may be done, when the specific indication to choose a particular modality no longer existWhen patient becomes hemodynamically stable, modality of RRT may be switched from CRRT and SLED to IHDGuidelines for termination of RRT in AKI are unclear and are empiric. An attempt may be made to withdraw RRT if spontaneous urine output is consistently more than 30 ml/min for at least 6–12 hIn case a decision to withdraw patients from RRT is made due to the futility of such therapy, it should be taken after much deliberation among all the members of medical care giver team and immediate family members.