Renal replacement therapy Indications
Indications, timing and patient selection for RRT
OVERVIEW
- Acute kidney injury (AKI) is common in critical illness, and severe AKI is associated with up to 60 % hospital mortality (Wierstra et al, 2016)
- Renal replacement therapy (RRT) may be provided by different modalities:
- Continuous RRT (CRRT) is most commonly used in Australasian ICUs
- Slow Low Efficiency Daily Dialysis (SLEDD) and Intermittent Haemodialysis (IHD) are important alternatives
- Different modalities may be better suited to different patient groups and different RRT indications, however, there is a lack of high-level patient-centered evidence to guide choice of modality in the ICU setting
- The timing of RRT initiation in critical illness — early or late — also remains controversial
INDICATIONS
Usual indications for RRT can be “renal” or “non-renal” – these can be summarised using the UFAKE mnemonic
Renal
- Uremia / azotaemia
- uraemic encephalopathy
- uraemic pericarditis
- uraemic haemorrhage
- consider if urea >30-35 mM (no strict cut-off)
- Fluid overload
- oliguria resulting in clinically significant volume overload and respiratory distress, that is refractory to medical management
- Metabolic acidosis due to renal failure (e.g. pH <7.2) – retention of acids + hyperchloraemia (tubular dysfunction)
- Hyperkalaemia (>6.0) (concurrent with medical management)
Non-renal (E: extras = TNT)
- Toxins/ drugs
- small, non-protein bound agents such as toxic alcohols, lithium, salicylate, theophylline, valproate
- Na+ 160mmol/L
- Temperature control hyperthermia
- Other controversial indications
- Prevention of contrast nephropathy (no evidence!)
- Sepsis — removal of cytokines by high volume haemofiltration (HVHF) remains controversial
- Rhabdomyolysis (usually RRT is only used when renal impairment occurs)
- MARS (“liver dialysis”)
TIMING
Starting RRT
- in general, RRT is started when one of the above indications is met
- However, the precise timing of initiation of RRT in critically ill patients is an area of controversy (see below)
Stopping RRT depends on multiples factors:
- resolution of the underlying cause
- e.g. passing 30mL/hr of urine and CrCl >12-20mL/min
- able to be managed effectively using other therapies (e.g. frusemide for fluid balance)
- logistical considerations, such as:
- filter lifespan in CRRT
- the timing of surgery
- when IHD can be commenced in persistent renal failure
PATIENT SELECTION
In general, patients who are critically ill are more suited to CRRT and this is the modality most widely used for RRT in Australasian intensive care.
CRRT is usually more appropriate for patients with
- haemodynamically instability
- increased intracranial pressure
- severe volume overload (CRRT can remove >200-300mL/h)
- mechanical ventilation
- high protein turnover/ hypercatabolism
- high risk of osmotic dysequilibrium (e.g. severe uraemia due to delayed presentation of renal failure)
IHD is more suited for patients who require rapid removal of dialysable substances
- chronic end-stage renal failure (ESRF) (CRRT is less efficient and inconvenient)
- hyperkalaemia
- selected toxins
EARLY VERSUS DELAYED INITIATION OF RRT IN THE CRITICALLY ILL
The timing of RRT initiation in critically ill patients is controversial
- current evidence is conflicting
- many competing factors need to be considered
Rationale for early RRT
- Allows early removal of toxic substances with physiological consequences
- these include
- urea (causes encephalopathy, pericarditis and platelet dysfunction)
- non-volatile acids (which cause acidosis)
- drugs required for therapy that can have adverse effects when they accumulate
- illness-specific agents, such as cytokines in sepsis, ammonia in severe liver dysfunction, intracellular substances released in rhabdomyolysis
- harmful effects from these toxic substances are generally dose-dependent — there is no critical threshold for harm — so early removal may limit potential harm and risk of organ dysfunction
- these include
- In some conditions, the need for RRT may be inevitable regardless of the current level of renal dysfunction (e.g. massive bilateral kidney trauma)
- Limits the risks and complications of alternative medical therapies used for renal impairment, such as:
- frusemide: ototoxicity
- resonium: bowel obstruction and perforation
- bicarbonate: hypernatraemia and hypercapnia
- RRT can simplify the management of critically ill patients with complex issues (e.g. combination of renal impairment, electrolyte derangement, fluid overload, hyperthermia, rhabdomyolysis in a patient with severe crush injury)
Rationale for delayed RRT
- 50% of patients randomised to the “delayed RRT” arm of the AKIKI trial never required RRT with no difference in survival or length-of-stay in ICU or in hospital
- Safety
- reduced exposure to the complications of:
- renal replacement therapy (e.g. exposure to an extracorporeal circuit, errors of adverse effects related to anticoagulation, fluid and electrolyte management)
- vascath insertion (e.g. vessel injury and bleeding, CLABSI (infection), and air embolism)
- reduced exposure to the complications of:
- Logistics
- RRT is relatively expensive, compared to the relatively inexpensive alternative medical therapies for managing renal impairment and its complications
- requires necessary equipment, skilled staff and monitoring
- increased workload for patient care
- Pathophysiology
- In general, RRT is only a supportive measure, not a curative therapy for acute kidney injury or its underlying cause
- RRT may contribute to delayed renal recovery (e.g. hypotension due to fluid removal, exposure to an extracorporeal circuit) (see here)
- RRT may remove beneficial substances (e.g. endogenous mediators, therapeutic drugs)
Evidence
- Systematic review (Wierstra et al, 2016)
- Earlier meta-analyses suggested that “early” RRT improves survival in critical illness, however, no survival benefit was seen in the subgroup of higher quality trials (RCTs)
- Systematic review of 36 studies (7 RCTs, 10 prospective cohorts, and 19 retrospective cohorts)
- n = 1042 patients from 9 studies were considered to be of high quality and were included for quantitative analysis
- No survival advantage was found with “early” RRT (OR 0.665; 95 % CI 0.384–1.153, p = 0.146)
- No survival difference in subgroup analysis of reason for ICU admission (surgical/medical) or definition of “early” (time/biochemical)
- No significant differences were observed in ICU or hospital LOS
- Conclusion
- no difference in survival or ICU/ hospital LOS with early or late RRT
- AKIKI and ELAIN trials were published after this systematic review
- AKIKI trial (Gaudry et al, 2006)
- multi-center RCT (31 French ICUs)
- n =620 critically ill adults with stage 3 AKI, as per the KDIGO criteria
- Intervention: immediate RRT (early RRT)
- Comparison: RRT initiation only when medically necessary (severe hyperkalemia, metabolic acidosis, pulmonary oedema, or a blood urea nitrogen level greater than 112 mg/dL, or oliguria for more than 72 hours) (late RRT)
- Outcomes:
- no difference in the primary outcome of 60-day mortality (48.5% vs 49.7% p-value of 0.79)
- no difference in secondary outcomes
- mortality at 30-days
- ICU length-of-stay
- long-term dialysis dependence
- ventilator-free days
- vasopressor-free days
- There were differences in:
- the proportion of patients that actually received RRT (98% in early RRT group versus 51% in the late RRT)
- how early patients experienced adequate urine production (defined as 1000 mL of urine in a 24-hour period without the help of diuretics) (earlier in the late RRT group)
- the rate of catheter-related bloodstream infections (10% in early RRT vs 5% in late RRT)
- Commentary and criticisms
- The type of RRT used was at the discretion of the treating physician and only 45% received CRRT, which is at odds with standard Australasian ICU practice
- Most of the patients in the late RRT group (68%) were dialysed because of either oliguria for > 72 hours, or a BUN greater than 112 mg/dL
- the majority were medical patients (80%, e.g. sepsis)
- Fragility index = “-18”
- the outcome is consistent with the pre-existing literature (see systematic review by Wierstra et al, 2016)
- ELAIN trial (Zarbock et al, 2016)
- single-center RCT from Germany
- n = 231 critically ill adults with stage 2 AKI
- Intervention: immediate RRT (early RRT)
- Comparison: RRT initiation only when stage 3 KDIGO criteria were met
- Outcomes:
- improved primary outcome of 90-day mortality in the early RRT group (39.3% versus 54.7%)
- secondary outcomes
- These favoured early RRT:
- duration of mechanical ventilation (median of 125.5h vs 181.0h).
- number of patients who still required RRT at 60-days (15.9% vs 23.7%)
- there was no difference in the recovery of renal function at 90-days (88.2% vs 85.2%) (secondary outcome)
- These favoured early RRT:
- Commentary and criticisms
- all patients received CVVHDF and were only transferred to IHD or SLEDD if RRT was required for more than 7 days
- the majority were surgical patients (47% were cardiac surgery)
- median time difference to initiation of dialysis between the immediate and delayed groups was 25.5 hours
- Fragility index = 3
- given the small trial size and that prior studies (see systematic review by Wierstra et al, 2016) the large mortality difference seen is this trial is unlikely to be true
- STARRT-AKI
- This is a large pragmatic international multi-center RCT, including ICUs in Australasia, that is currently in progress comparing early versus delayed RRT
- IDEAL-ICU
- Another French multi-center RCT is also in progress comparing early versus late RRT in the critically ill
RENAL REPLACEMENT THERAPY IN TOXICOLOGY
Renal replacement therapy is clinically useful for enhanced elimination of selected toxic agents
- The RRT mode (IHD versus CRRT) and duration is important and the optimal choice varies depending on the agent
- At present, there is a lack of high-level evidence guiding the use of RRT in toxicology
- Existing evidence has been critically appraised and expert consensus guidelines have been created by the EXTRIP workgroup
Table from Kellum et al (2016):
1 | 2 | 3 |
---|---|---|
Methanol | IHD | RRT should be continued until the serum methanol concentration is < 25 mg/dL and the anion-gap metabolic acidosis and osmolal gap are normal. Rebound may occur up to 36 h |
Isopropanol | IHD | RRT effectively removes isopropanol and acetone, although it is usually unnecessary except in severe cases (prolonged coma, myocardial depression, renal failure) |
Ethylene glycol | IHD | RRT should be continued until the ethylene glycol level is <20 mg/dL and metabolic acidosis or other signs of systemic toxicity have been resolved bound. Rebound may occur up to 24 hours |
Lithium | IHD CRRT | IHD removes lithium faster but rebound may be a significant problem and can be addressed effectively with CRRT |
Salicylate | IHD CRRT | Both IHD/CRRT have been reported in the management of salicylate poisoning |
Theophylline | IHD CRRT haemoperfusion | RRT should be continued until clinical improvement and a plasma level < 20 mg/L is obtained bound may occur. Rebound may occur |
Valproic acid | IHD CRRT haemoperfusion | At supratherapeutic drug level plasma proteins become saturated and the fraction of unbound drug increases substantially and becomes dialysable |
References and Links
Introduction to ICU Series
Introduction to ICU Series Landing Page
DAY TO DAY ICU: FASTHUG, ICU Ward Round, Clinical Examination, Communication in a Crisis, Documenting the ward round in ICU, Human Factors
AIRWAY: Bag Valve Mask Ventilation, Oropharyngeal Airway, Nasopharyngeal Airway, Endotracheal Tube (ETT), Tracheostomy Tubes
BREATHING: Positive End Expiratory Pressure (PEEP), High Flow Nasal Prongs (HFNP), Intubation and Mechanical Ventilation, Mechanical Ventilation Overview, Non-invasive Ventilation (NIV)
CIRCULATION: Arrhythmias, Atrial Fibrillation, ICU after Cardiac Surgery, Pacing Modes, ECMO, Shock
CNS: Brain Death, Delirium in the ICU, Examination of the Unconscious Patient, External-ventricular Drain (EVD), Sedation in the ICU
GASTROINTESTINAL: Enteral Nutrition vs Parenteral Nutrition, Intolerance to EN, Prokinetics, Stress Ulcer Prophylaxis (SUP), Ileus
GENITOURINARY: Acute Kidney Injury (AKI), CRRT Indications
HAEMATOLOGICAL: Anaemia, Blood Products, Massive Transfusion Protocol (MTP)
INFECTIOUS DISEASE: Antimicrobial Stewardship, Antimicrobial Quick Reference, Central Line Associated Bacterial Infection (CLABSI), Handwashing in ICU, Neutropenic Sepsis, Nosocomial Infections, Sepsis Overview
SPECIAL GROUPS IN ICU: Early Management of the Critically Ill Child, Paediatric Formulas, Paediatric Vital Signs, Pregnancy and ICU, Obesity, Elderly
FLUIDS AND ELECTROLYTES: Albumin vs 0.9% Saline, Assessing Fluid Status, Electrolyte Abnormalities, Hypertonic Saline
PHARMACOLOGY: Drug Infusion Doses, Summary of Vasopressors, Prokinetics, Steroid Conversion, GI Drug Absorption in Critical Illness
PROCEDURES: Arterial line, CVC, Intercostal Catheter (ICC), Intraosseous Needle, Underwater seal drain, Naso- and Orogastric Tubes (NGT/OGT), Rapid Infusion Catheter (RIC)
INVESTIGATIONS: ABG Interpretation, Echo in ICU, CXR in ICU, Routine daily CXR, FBC, TEG/ROTEM, US in Critical Care
ICU MONITORING: NIBP vs Arterial line, Arterial Line Pressure Transduction, Cardiac Output, Central Venous Pressure (CVP), CO2 / Capnography, Pulmonary Artery Catheter (PAC / Swan-Ganz), Pulse Oximeter
Journal articles and textbooks
- Bagshaw SM, Lamontagne F, Joannidis M, Wald R. When to start renal replacement therapy in critically ill patients with acute kidney injury: comment on AKIKI and ELAIN. Critical care. 2016; 20(1):245. [pubmed]
- Gaudry S,Hajage D, Schortgen F, et al. Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med. 2016; 375(2):122-33. [pubmed]
- Kellum,JA, Bellomo R, Ronco C. Continuous Renal Replacement Therapy. Oxford University Press, 2016. [Google books]
- Ghannoum M, Nolin TD, Lavergne V, et al. Blood purification in toxicology: nephrology’s ugly duckling. Advances in chronic kidney disease. 2011; 18(3):160-6. [pubmed] [article]
- Wald R, Adhikari NK, Smith OM, et al; Canadian Critical Care Trials Group. Comparison of standard and accelerated initiation of renal replacement therapy in acute kidney injury. Kidney Int. 2015;88(4):897-904. [pubmed]
- Wierstra BT, Kadri S, Alomar S, et al. The impact of “early” versus “late” initiation of renal replacement therapy in critical care patients with acute kidney injury: a systematic review and evidence synthesis. Critical care. 2016; 20(1):122. [pubmed]
- Zarbock A, Kellum JA, Schmidt C, et al. Effect of Early vs Delayed Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients With Acute Kidney Injury: The ELAIN Randomized Clinical Trial. JAMA. 2016;315(20):2190-9. [pubmed]
FOAM and web resources
- CC Nerd — The Case of the Afflicted Kidney by Rory Spiegel (2016)
- EXTRIP workgroup
- The Bottom Line — ELAIN trial (2016)
- The Bottom Line — AKIKI trial (2016)
- The Bottom Line — Editorial: Early vs Late Renal Replacement Therapy (2016)
Critical Care
Compendium
Chris is an Intensivist and ECMO specialist at The Alfred ICU, where he is Deputy Director (Education). He is a Clinical Adjunct Associate Professor at Monash University, the Lead for the Clinician Educator Incubator programme, and a CICM First Part Examiner.
He is an internationally recognised Clinician Educator with a passion for helping clinicians learn and for improving the clinical performance of individuals and collectives. He was one of the founders of the FOAM movement (Free Open-Access Medical education) has been recognised for his contributions to education with awards from ANZICS, ANZAHPE, and ACEM.
His one great achievement is being the father of three amazing children.
On Bluesky, he is @precordialthump.bsky.social and on the site that Elon has screwed up, he is @precordialthump.
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