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
- Hsu CY, Ordoñez JD, Chertow GM, et al. The risk of acute renal failure in patients with chronic kidney disease. Kidney Int 2008; 74:101.
- Goldstein SL, Somers MJ, Baum MA, et al. Pediatric patients with multi-organ dysfunction syndrome receiving continuous renal replacement therapy. Kidney Int 2005; 67:653.
- Payen D, de Pont AC, Sakr Y, et al. A positive fluid balance is associated with a worse outcome in patients with acute renal failure. Crit Care 2008; 12:R74.
- Bouchard J, Soroko SB, Chertow GM, et al. Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int 2009; 76:422.
- Gaudry S, Hajage D, Schortgen F, et al. Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit. N Engl J Med 2016; 375:122.
- Jamale TE, Hase NK, Kulkarni M, et al. Earlier-start versus usual-start dialysis in patients with community-acquired acute kidney injury: a randomized controlled trial. Am J Kidney Dis 2013; 62:1116.
- Wald R, Adhikari NK, Smith OM, et al. Comparison of standard and accelerated initiation of renal replacement therapy in acute kidney injury. Kidney Int 2015; 88:897.
- Bouman CS, Oudemans-Van Straaten HM, Tijssen JG, et al. Effects of early high-volume continuous venovenous hemofiltration on survival and recovery of renal function in intensive care patients with acute renal failure: a prospective, randomized trial. Crit Care Med 2002; 30:2205.
- Combes A, Bréchot N, Amour J, et al. Early High-Volume Hemofiltration versus Standard Care for Post-Cardiac Surgery Shock. The HEROICS Study. Am J Respir Crit Care Med 2015; 192:1179.
- 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; 315:2190.
- Bhatt GC, Das RR. Early versus late initiation of renal replacement therapy in patients with acute kidney injury-a systematic review & meta-analysis of randomized controlled trials. BMC Nephrol 2017; 18:78.
- Chertow GM, Winkelmayer WC. Early to Dialyze: Healthy and Wise? JAMA 2016; 315:2171.
- KDIGO clinical practice guidelines for acute kidney injury. Kidney Int Suppl 2012; 2.
- van Bommel EF, Ponssen HH. Intermittent versus continuous treatment for acute renal failure: where do we stand? Am J Kidney Dis 1997; 30:S72.
- Lameire N, Van Biesen W, Vanholder R. Dialysing the patient with acute renal failure in the ICU: the emperor's clothes? Nephrol Dial Transplant 1999; 14:2570.
- Bellomo R, Boyce N. Acute continuous hemodiafiltration: a prospective study of 110 patients and a review of the literature. Am J Kidney Dis 1993; 21:508.
- Bellomo R, Farmer M, Parkin G, et al. Severe acute renal failure: a comparison of acute continuous hemodiafiltration and conventional dialytic therapy. Nephron 1995; 71:59.
- van Bommel E, Bouvy ND, So KL, et al. Acute dialytic support for the critically ill: intermittent hemodialysis versus continuous arteriovenous hemodiafiltration. Am J Nephrol 1995; 15:192.
- Swartz RD, Messana JM, Orzol S, Port FK. Comparing continuous hemofiltration with hemodialysis in patients with severe acute renal failure. Am J Kidney Dis 1999; 34:424.
- Guérin C, Girard R, Selli JM, Ayzac L. Intermittent versus continuous renal replacement therapy for acute renal failure in intensive care units: results from a multicenter prospective epidemiological survey. Intensive Care Med 2002; 28:1411.
- Cho KC, Himmelfarb J, Paganini E, et al. Survival by dialysis modality in critically ill patients with acute kidney injury. J Am Soc Nephrol 2006; 17:3132.
- Vinsonneau C, Camus C, Combes A, et al. Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. Lancet 2006; 368:379.
- Mehta RL, McDonald B, Gabbai FB, et al. A randomized clinical trial of continuous versus intermittent dialysis for acute renal failure. Kidney Int 2001; 60:1154.
- Augustine JJ, Sandy D, Seifert TH, Paganini EP. A randomized controlled trial comparing intermittent with continuous dialysis in patients with ARF. Am J Kidney Dis 2004; 44:1000.
- Uehlinger DE, Jakob SM, Ferrari P, et al. Comparison of continuous and intermittent renal replacement therapy for acute renal failure. Nephrol Dial Transplant 2005; 20:1630.
- Schefold JC, von Haehling S, Pschowski R, et al. The effect of continuous versus intermittent renal replacement therapy on the outcome of critically ill patients with acute renal failure (CONVINT): a prospective randomized controlled trial. Crit Care 2014; 18:R11.
- Kellum JA, Angus DC, Johnson JP, et al. Continuous versus intermittent renal replacement therapy: a meta-analysis. Intensive Care Med 2002; 28:29.
- Tonelli M, Manns B, Feller-Kopman D. Acute renal failure in the intensive care unit: a systematic review of the impact of dialytic modality on mortality and renal recovery. Am J Kidney Dis 2002; 40:875.
- Rabindranath K, Adams J, Macleod AM, Muirhead N. Intermittent versus continuous renal replacement therapy for acute renal failure in adults. Cochrane Database Syst Rev 2007; :CD003773.
- Bagshaw SM, Berthiaume LR, Delaney A, Bellomo R. Continuous versus intermittent renal replacement therapy for critically ill patients with acute kidney injury: a meta-analysis. Crit Care Med 2008; 36:610.
- Pannu N, Klarenbach S, Wiebe N, et al. Renal replacement therapy in patients with acute renal failure: a systematic review. JAMA 2008; 299:793.
- Schneider AG, Bellomo R, Bagshaw SM, et al. Choice of renal replacement therapy modality and dialysis dependence after acute kidney injury: a systematic review and meta-analysis. Intensive Care Med 2013; 39:987.
- Schiffl H, Lang SM, Fischer R. Daily hemodialysis and the outcome of acute renal failure. N Engl J Med 2002; 346:305.
- Manns B, Doig CJ, Lee H, et al. Cost of acute renal failure requiring dialysis in the intensive care unit: clinical and resource implications of renal recovery. Crit Care Med 2003; 31:449.
- Jacka MJ, Ivancinova X, Gibney RT. Continuous renal replacement therapy improves renal recovery from acute renal failure. Can J Anaesth 2005; 52:327.
- Bell M, SWING, Granath F, et al. Continuous renal replacement therapy is associated with less chronic renal failure than intermittent haemodialysis after acute renal failure. Intensive Care Med 2007; 33:773.
- Palevsky PM. Dialysis modality and dosing strategy in acute renal failure. Semin Dial 2006; 19:165.
- Palevsky PM, Baldwin I, Davenport A, et al. Renal replacement therapy and the kidney: minimizing the impact of renal replacement therapy on recovery of acute renal failure. Curr Opin Crit Care 2005; 11:548.
- Ronco C, Tetta C, Mariano F, et al. Interpreting the mechanisms of continuous renal replacement therapy in sepsis: the peak concentration hypothesis. Artif Organs 2003; 27:792.
- Sanchez-Izquierdo JA, Perez Vela JL, Lozano Quintana MJ, et al. Cytokines clearance during venovenous hemofiltration in the trauma patient. Am J Kidney Dis 1997; 30:483.
- Kellum JA, Johnson JP, Kramer D, et al. Diffusive vs. convective therapy: effects on mediators of inflammation in patient with severe systemic inflammatory response syndrome. Crit Care Med 1998; 26:1995.
- Friedrich JO, Wald R, Bagshaw SM, et al. Hemofiltration compared to hemodialysis for acute kidney injury: systematic review and meta-analysis. Crit Care 2012; 16:R146.
- Joannes-Boyau O, Honoré PM, Perez P, et al. High-volume versus standard-volume haemofiltration for septic shock patients with acute kidney injury (IVOIRE study): a multicentre randomized controlled trial. Intensive Care Med 2013; 39:1535.
- Davenport A, Will EJ, Davison AM. Continuous vs. intermittent forms of haemofiltration and/or dialysis in the management of acute renal failure in patients with defective cerebral autoregulation at risk of cerebral oedema. Contrib Nephrol 1991; 93:225.
- Kielstein JT, Kretschmer U, Ernst T, et al. Efficacy and cardiovascular tolerability of extended dialysis in critically ill patients: a randomized controlled study. Am J Kidney Dis 2004; 43:342.
- Abe M, Okada K, Suzuki M, et al. Comparison of sustained hemodiafiltration with continuous venovenous hemodiafiltration for the treatment of critically ill patients with acute kidney injury. Artif Organs 2010; 34:331.
- Schwenger V, Weigand MA, Hoffmann O, et al. Sustained low efficiency dialysis using a single-pass batch system in acute kidney injury - a randomized interventional trial: the REnal Replacement Therapy Study in Intensive Care Unit PatiEnts. Crit Care 2012; 16:R140.
- Zhang L, Yang J, Eastwood GM, et al. Extended Daily Dialysis Versus Continuous Renal Replacement Therapy for Acute Kidney Injury: A Meta-analysis. Am J Kidney Dis 2015; 66:322.
- Phu NH, Hien TT, Mai NT, et al. Hemofiltration and peritoneal dialysis in infection-associated acute renal failure in Vietnam. N Engl J Med 2002; 347:895.
- Gabriel DP, Caramori JT, Martim LC, et al. High volume peritoneal dialysis vs daily hemodialysis: a randomized, controlled trial in patients with acute kidney injury. Kidney Int Suppl 2008; :S87.
- Chionh CY, Soni SS, Finkelstein FO, et al. Use of peritoneal dialysis in AKI: a systematic review. Clin J Am Soc Nephrol 2013; 8:1649.
- Paganini EP, Tapolyai M, Goomastic M, et al. Establishing a dialysis therapy/patient outcome link in intensive care unit acute dialysis for patients with acute renal failure. Am J Kidney Dis 1996; 28(Suppl 3):S81.
- VA/NIH Acute Renal Failure Trial Network, Palevsky PM, Zhang JH, et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med 2008; 359:7.
- Palevsky PM, Liu KD, Brophy PD, et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for acute kidney injury. Am J Kidney Dis 2013; 61:649.
- Overberger P, Pesacreta M, Palevsky PM, VA/NIH Acute Renal Failure Trial Network. Management of renal replacement therapy in acute kidney injury: a survey of practitioner prescribing practices. Clin J Am Soc Nephrol 2007; 2:623.
- Faulhaber-Walter R, Hafer C, Jahr N, et al. The Hannover Dialysis Outcome study: comparison of standard versus intensified extended dialysis for treatment of patients with acute kidney injury in the intensive care unit. Nephrol Dial Transplant 2009; 24:2179.
- Ronco C, Bellomo R, Homel P, et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial. Lancet 2000; 356:26.
- Saudan P, Niederberger M, De Seigneux S, et al. Adding a dialysis dose to continuous hemofiltration increases survival in patients with acute renal failure. Kidney Int 2006; 70:1312.
- Tolwani AJ, Campbell RC, Stofan BS, et al. Standard versus high-dose CVVHDF for ICU-related acute renal failure. J Am Soc Nephrol 2008; 19:1233.
- Jun M, Heerspink HJ, Ninomiya T, et al. Intensities of renal replacement therapy in acute kidney injury: a systematic review and meta-analysis. Clin J Am Soc Nephrol 2010; 5:956.
- Van Wert R, Friedrich JO, Scales DC, et al. High-dose renal replacement therapy for acute kidney injury: Systematic review and meta-analysis. Crit Care Med 2010; 38:1360.
- Fayad AI, Buamscha DG, Ciapponi A. Intensity of continuous renal replacement therapy for acute kidney injury. Cochrane Database Syst Rev 2016; 10:CD010613.
- RENAL Replacement Therapy Study Investigators, Bellomo R, Cass A, et al. Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med 2009; 361:1627.
- Vesconi S, Cruz DN, Fumagalli R, et al. Delivered dose of renal replacement therapy and mortality in critically ill patients with acute kidney injury. Crit Care 2009; 13:R57.
- 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
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS