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Dialysis-related factors that may influence recovery of renal function in acute kidney injury (acute renal failure)

Edward D Siew, MD, MSCI
Thomas A Golper, MD
Section Editors
Steve J Schwab, MD
Paul M Palevsky, MD
Deputy Editor
Alice M Sheridan, MD


Dialysis-requiring acute kidney injury (AKI-D) affects a large percentage of hospitalized and, particularly, critically ill patients [1-6]. The incidence is increasing by 10 percent per year and affects approximately 0.4 percent of hospitalized patients and between 3 to 13 percent of critically ill patients [1-6].

The reasons for this growth are not known, though an aging population, broadening array of nephrotoxins, growth in conditions associated with AKI such as sepsis, and a liberalization of thresholds to initiate renal replacement therapy (RRT) are likely contributors [7-10].

Patients who survive AKI-D are at risk for permanent loss of kidney function and poor quality of life [11-16]. Cardiovascular risks and mortality are increased when kidney function does not recover [17,18].

This topic reviews dialysis-related factors that may influence the recovery from AKI-D. Overall outcomes of AKI and patient-related risk factors that may affect recovery of renal function are discussed elsewhere. (See "Kidney and patient outcomes after acute kidney injury in adults", section on 'Degree of recovery'.)

The indications, prescriptions, dose, and modalities of RRT in AKI are discussed separately. (See "Renal replacement therapy (dialysis) in acute kidney injury in adults: Indications, timing, and dialysis dose" and "Renal replacement therapy (dialysis) in acute kidney injury: Metabolic and hemodynamic considerations".)

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Literature review current through: Sep 2017. | This topic last updated: Dec 16, 2016.
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  1. Hoste EA, Bagshaw SM, Bellomo R, et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Med 2015; 41:1411.
  2. Uchino S. The epidemiology of acute renal failure in the world. Curr Opin Crit Care 2006; 12:538.
  3. Hsu RK, McCulloch CE, Dudley RA, et al. Temporal changes in incidence of dialysis-requiring AKI. J Am Soc Nephrol 2013; 24:37.
  4. Waikar SS, Curhan GC, Wald R, et al. Declining mortality in patients with acute renal failure, 1988 to 2002. J Am Soc Nephrol 2006; 17:1143.
  5. Hsu CY, McCulloch CE, Fan D, et al. Community-based incidence of acute renal failure. Kidney Int 2007; 72:208.
  6. Wald R, McArthur E, Adhikari NK, et al. Changing incidence and outcomes following dialysis-requiring acute kidney injury among critically ill adults: a population-based cohort study. Am J Kidney Dis 2015; 65:870.
  7. Hsu RK, McCulloch CE, Heung M, et al. Exploring Potential Reasons for the Temporal Trend in Dialysis-Requiring AKI in the United States. Clin J Am Soc Nephrol 2016; 11:14.
  8. Siew ED, Davenport A. The growth of acute kidney injury: a rising tide or just closer attention to detail? Kidney Int 2015; 87:46.
  9. Dombrovskiy VY, Martin AA, Sunderram J, Paz HL. Rapid increase in hospitalization and mortality rates for severe sepsis in the United States: a trend analysis from 1993 to 2003. Crit Care Med 2007; 35:1244.
  10. Siddiqui NF, Coca SG, Devereaux PJ, et al. Secular trends in acute dialysis after elective major surgery--1995 to 2009. CMAJ 2012; 184:1237.
  11. Lo LJ, Go AS, Chertow GM, et al. Dialysis-requiring acute renal failure increases the risk of progressive chronic kidney disease. Kidney Int 2009; 76:893.
  12. Wald R, Quinn RR, Luo J, et al. Chronic dialysis and death among survivors of acute kidney injury requiring dialysis. JAMA 2009; 302:1179.
  13. Coca SG, Singanamala S, Parikh CR. Chronic kidney disease after acute kidney injury: a systematic review and meta-analysis. Kidney Int 2012; 81:442.
  14. James MT, Ghali WA, Tonelli M, et al. Acute kidney injury following coronary angiography is associated with a long-term decline in kidney function. Kidney Int 2010; 78:803.
  15. Chawla LS, Eggers PW, Star RA, Kimmel PL. Acute kidney injury and chronic kidney disease as interconnected syndromes. N Engl J Med 2014; 371:58.
  16. Johansen KL, Smith MW, Unruh ML, et al. Predictors of health utility among 60-day survivors of acute kidney injury in the Veterans Affairs/National Institutes of Health Acute Renal Failure Trial Network Study. Clin J Am Soc Nephrol 2010; 5:1366.
  17. Hsu CY, Chertow GM, McCulloch CE, et al. Nonrecovery of kidney function and death after acute on chronic renal failure. Clin J Am Soc Nephrol 2009; 4:891.
  18. Sawhney S, Mitchell M, Marks A, et al. Long-term prognosis after acute kidney injury (AKI): what is the role of baseline kidney function and recovery? A systematic review. BMJ Open 2015; 5:e006497.
  19. Conger JD, Robinette JB, Schrier RW. Smooth muscle calcium and endothelium-derived relaxing factor in the abnormal vascular responses of acute renal failure. J Clin Invest 1988; 82:532.
  20. Conger JD, Robinette JB, Hammond WS. Differences in vascular reactivity in models of ischemic acute renal failure. Kidney Int 1991; 39:1087.
  21. Solez K, Morel-Maroger L, Sraer JD. The morphology of "acute tubular necrosis" in man: analysis of 57 renal biopsies and a comparison with the glycerol model. Medicine (Baltimore) 1979; 58:362.
  22. Myers BD, Moran SM. Hemodynamically mediated acute renal failure. N Engl J Med 1986; 314:97.
  23. Venkatachalam MA, Griffin KA, Lan R, et al. Acute kidney injury: a springboard for progression in chronic kidney disease. Am J Physiol Renal Physiol 2010; 298:F1078.
  24. Abuelo JG. Normotensive ischemic acute renal failure. N Engl J Med 2007; 357:797.
  25. Mehta RL, Bouchard J, Soroko SB, et al. Sepsis as a cause and consequence of acute kidney injury: Program to Improve Care in Acute Renal Disease. Intensive Care Med 2011; 37:241.
  26. Himmelfarb J, Le P, Klenzak J, et al. Impaired monocyte cytokine production in critically ill patients with acute renal failure. Kidney Int 2004; 66:2354.
  27. Roberts DM, Liu X, Roberts JA, et al. A multicenter study on the effect of continuous hemodiafiltration intensity on antibiotic pharmacokinetics. Crit Care 2015; 19:84.
  28. Mueller BA, Pasko DA, Sowinski KM. Higher renal replacement therapy dose delivery influences on drug therapy. Artif Organs 2003; 27:808.
  29. Eyler RF, Mueller BA, Medscape. Antibiotic dosing in critically ill patients with acute kidney injury. Nat Rev Nephrol 2011; 7:226.
  30. Fissell WH. Antimicrobial dosing in acute renal replacement. Adv Chronic Kidney Dis 2013; 20:85.
  31. Nolin TD, Aronoff GR, Fissell WH, et al. Pharmacokinetic assessment in patients receiving continuous RRT: perspectives from the Kidney Health Initiative. Clin J Am Soc Nephrol 2015; 10:159.
  32. Oudemans-van Straaten HM, Bosman RJ, Koopmans M, et al. Citrate anticoagulation for continuous venovenous hemofiltration. Crit Care Med 2009; 37:545.
  33. Gritters M, Grooteman MP, Schoorl M, et al. Citrate anticoagulation abolishes degranulation of polymorphonuclear cells and platelets and reduces oxidative stress during haemodialysis. Nephrol Dial Transplant 2006; 21:153.
  34. Oudemans-van Straaten HM, Ostermann M. Bench-to-bedside review: Citrate for continuous renal replacement therapy, from science to practice. Crit Care 2012; 16:249.
  35. Böhler J, Schollmeyer P, Dressel B, et al. Reduction of granulocyte activation during hemodialysis with regional citrate anticoagulation: dissociation of complement activation and neutropenia from neutrophil degranulation. J Am Soc Nephrol 1996; 7:234.
  36. Ikizler TA, Flakoll PJ, Parker RA, Hakim RM. Amino acid and albumin losses during hemodialysis. Kidney Int 1994; 46:830.
  37. Umber A, Wolley MJ, Golper TA, et al. Amino acid losses during sustained low efficiency dialysis in critically ill patients with acute kidney injury. Clin Nephrol 2014; 81:93.
  38. Mokrzycki MH, Kaplan AA. Protein losses in continuous renal replacement therapies. J Am Soc Nephrol 1996; 7:2259.
  39. Frankenfield DC, Reynolds HN. Nutritional effect of continuous hemodiafiltration. Nutrition 1995; 11:388.
  40. Himmelfarb J, Zaoui P, Hakim R. Modulation of granulocyte LAM-1 and MAC-1 during dialysis--a prospective, randomized controlled trial. Kidney Int 1992; 41:388.
  41. Hakim RM, Wingard RL, Parker RA. Effect of the dialysis membrane in the treatment of patients with acute renal failure. N Engl J Med 1994; 331:1338.
  42. Schiffl H, Lang SM, König A, et al. Biocompatible membranes in acute renal failure: prospective case-controlled study. Lancet 1994; 344:570.
  43. Subramanian S, Venkataraman R, Kellum JA. Influence of dialysis membranes on outcomes in acute renal failure: a meta-analysis. Kidney Int 2002; 62:1819.
  44. Gastaldello K, Melot C, Kahn RJ, et al. Comparison of cellulose diacetate and polysulfone membranes in the outcome of acute renal failure. A prospective randomized study. Nephrol Dial Transplant 2000; 15:224.
  45. Alonso A, Lau J, Jaber BL. Biocompatible hemodialysis membranes for acute renal failure. Cochrane Database Syst Rev 2008; :CD005283.
  46. KDIGO clinical practice guidelines for acute kidney injury. Kidney Int Suppl 2012; 2.
  47. 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.
  48. Marshall, MR, Golper, TA. Intermittent Hemodialysis in Intensive Care in Nephrology, Murray, P, Brady, H, Hall, J (Eds), Taylor & Francis, Oxford, UK 2005.
  49. Ponikvar JB, Rus RR, Kenda RB, et al. Low-flux versus high-flux synthetic dialysis membrane in acute renal failure: prospective randomized study. Artif Organs 2001; 25:946.
  50. Locatelli F, Martin-Malo A, Hannedouche T, et al. Effect of membrane permeability on survival of hemodialysis patients. J Am Soc Nephrol 2009; 20:645.
  51. Eknoyan G, Beck GJ, Cheung AK, et al. Effect of dialysis dose and membrane flux in maintenance hemodialysis. N Engl J Med 2002; 347:2010.
  52. 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.
  53. Ostermann M, Dickie H, Barrett NA. Renal replacement therapy in critically ill patients with acute kidney injury--when to start. Nephrol Dial Transplant 2012; 27:2242.
  54. Liu KD, Himmelfarb J, Paganini E, et al. Timing of initiation of dialysis in critically ill patients with acute kidney injury. Clin J Am Soc Nephrol 2006; 1:915.
  55. Bagshaw SM, Uchino S, Bellomo R, et al. Timing of renal replacement therapy and clinical outcomes in critically ill patients with severe acute kidney injury. J Crit Care 2009; 24:129.
  56. Karvellas CJ, Farhat MR, Sajjad I, et al. A comparison of early versus late initiation of renal replacement therapy in critically ill patients with acute kidney injury: a systematic review and meta-analysis. Crit Care 2011; 15:R72.
  57. Carl DE, Grossman C, Behnke M, et al. Effect of timing of dialysis on mortality in critically ill, septic patients with acute renal failure. Hemodial Int 2010; 14:11.
  58. Shiao CC, Wu VC, Li WY, et al. Late initiation of renal replacement therapy is associated with worse outcomes in acute kidney injury after major abdominal surgery. Crit Care 2009; 13:R171.
  59. Vaara ST, Reinikainen M, Wald R, et al. Timing of RRT based on the presence of conventional indications. Clin J Am Soc Nephrol 2014; 9:1577.
  60. Seabra VF, Balk EM, Liangos O, et al. Timing of renal replacement therapy initiation in acute renal failure: a meta-analysis. Am J Kidney Dis 2008; 52:272.
  61. Durmaz I, Yagdi T, Calkavur T, et al. Prophylactic dialysis in patients with renal dysfunction undergoing on-pump coronary artery bypass surgery. Ann Thorac Surg 2003; 75:859.
  62. 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.
  63. 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.
  64. 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.
  65. 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.
  66. 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.
  67. 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.
  68. Mc Causland FR, Asafu-Adjei J, Betensky RA, et al. Comparison of Urine Output among Patients Treated with More Intensive Versus Less Intensive RRT: Results from the Acute Renal Failure Trial Network Study. Clin J Am Soc Nephrol 2016; 11:1335.
  69. Yeh BP, Tomko DJ, Stacy WK, et al. Factors influencing sodium and water excretion in uremic man. Kidney Int 1975; 7:103.
  70. Finn WF. Nephron heterogeneity in polyuric acute renal failure. J Lab Clin Med 1981; 98:21.
  71. Smyth A, Tan KH, Hyman-Taylor P, et al. Once versus three-times daily regimens of tobramycin treatment for pulmonary exacerbations of cystic fibrosis--the TOPIC study: a randomised controlled trial. Lancet 2005; 365:573.