Renal replacement therapy (dialysis) in acute kidney injury in adults: Indications, timing, and dialysis dose
- Paul M Palevsky, MD
Paul M Palevsky, MD
- Section Editor — Renal Failure
- Professor of Medicine
- University of Pittsburgh
- VA Pittsburgh Healthcare System
The management of patients with acute kidney injury (AKI) is supportive, with renal replacement therapy (RRT) indicated in patients with severe kidney injury. Multiple modalities of RRT are available. These include intermittent hemodialysis (IHD); continuous renal replacement therapies (CRRTs); and hybrid therapies, also known as prolonged intermittent renal replacement therapies (PIRRTs), such as sustained low-efficiency dialysis (SLED) and extended-duration dialysis (EDD). Despite these varied techniques, mortality in patients with AKI remains high, exceeding 40 to 50 percent in severely ill patients. (See "Renal and patient outcomes after acute tubular necrosis".)
The initiation of RRT in patients with AKI prevents uremia and immediate death from the adverse complications of renal failure. It is possible that variations in the timing of initiation, modalities, and/or dosing may affect clinical outcomes, particularly survival, although few studies have directly examined these issues.
The optimal timing, type of modality, and dosing strategy for patients with AKI who require RRT is reviewed here. The different modalities are discussed separately. (See "Continuous renal replacement therapies: Overview" and "Continuous renal replacement therapy in acute kidney injury (acute renal failure)" and "Continuous venovenous hemodiafiltration: Technical considerations" and "Continuous venovenous hemodialysis: Technical considerations" and "Sustained low efficiency or extended daily dialysis".)
Accepted urgent indications for RRT in patients with AKI generally include:
●Refractory fluid overload
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- URGENT INDICATIONS
- TIMING OF ELECTIVE INITIATION
- OPTIMAL MODALITY
- Continuous renal replacement therapies versus intermittent hemodialysis
- Prolonged intermittent renal replacement therapy
- Peritoneal dialysis
- OPTIMAL DOSING
- Intermittent hemodialysis
- Continuous renal replacement therapy
- DISCONTINUATION OF THERAPY
- SUMMARY AND RECOMMENDATIONS