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Current state of the art for renal replacement therapy in critically ill patients with acute kidney injury

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Abstract

Acute kidney injury (AKI) is associated with incremental risk for death and chronic kidney disease and represents a mounting clinical challenge for healthcare professionals. Renal replacement therapy (RRT) use in ICU settings is rising, likely in response to similar trends in AKI, taken together with an ageing population burdened by high prevalence of multi-morbidity and high illness acuity. Numerous features of RRT prescription and delivery are not standardized, nor are they supported from high-quality evidence derived from randomized trials. Despite the publication of rigorous clinical practice guidelines focused on RRT for AKI that are intended to optimize the quality and reliability of RRT in ICU settings, practice patterns and outcomes continue to show significant variability. In this concise review, we aim to summarize new knowledge and recent advances for the provision of RRT for critically ill patients with AKI.

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Abbreviations

AKI:

Acute kidney injury

BMI:

Body mass index

CKD:

Chronic kidney disease

CRBSI:

Catheter-related bloodstream infection

CRRT:

Continuous renal replacement therapy

CVVH:

Continuous veno-venous hemofiltration

CVVHD:

Continuous veno-venous hemodialysis

CVVHDF:

Continuous veno-venous hemodiafiltration

EBP:

Extracorporeal blood purification

EDD:

Extended daily dialysis

ESKD:

End-stage kidney disease

HDF:

Hemodiafiltration

HRQL:

Health-related quality of life

ICU:

Intensive care unit

IHD:

Intermittent hemodialysis

KDIGO:

Kidney Disease Improving Global Outcomes

MV:

Mechanical ventilation

MW:

Molecular weight

PD:

Peritoneal dialysis

PIRRT:

Prolonged intermittent renal replacement therapy

RCA:

Regional citrate anticoagulation

RCT:

Randomized controlled trial

RRT:

Renal replacement therapy

SLED:

Sustained low efficiency dialysis

UFH:

Unfractionated heparin

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Acknowledgements

Dr. Bagshaw is supported by a Canada Research Chair in Critical Care Nephrology.

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Correspondence to Sean M. Bagshaw.

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Conflicts of interest

Dr. Bagshaw has consulted for and received fees and grants from Baxter Healthcare Corp., and received fees from La Jolla Pharmaceuticals. Dr. Darmon has received speaker fees from Astellas, MSD, and Bristol Myers-Squibb, research support from Astute Medical, research grant from MSD, and funds for organizing educational meetings from MSD, Astellas, and Jazz Pharmaceutical. Dr. Ostermann received speaker fees and research support from Fresenius Medical Care and Baxter Healthcare Corp. Dr. Finkelstein has no conflicts to declare. Dr. Wald has received grants from Baxter Healthcare Corp. Dr. Tolwani has consulted and received fees from Baxter Healthcare Corp. and received educational grants from Baxter Healthcare Corp, NxStage, and DaVita. Dr. Goldstein reports grants from Gambro Renal Products, grants from National Institutes of Health, during the conduct of the study; grants and personal fees from Baxter Healthcare, grants and personal fees from Astute Medical, grants and personal fees from Bellco, grants and personal fees from AM Pharma, personal fees from Bioporto, personal fees from Akebia, personal fees from Otsuka, personal fees from Kaneka, grants from VitaFlo, grants from Mallinckrodt, grants from Alexion, grants and personal fees from La Jolla Pharmaceuticals, personal fees from MediBeacon, all outside the submitted work. Dr. Gattas’ institution has received educational and research support grants from Baxter Healthcare Corp. for unrelated projects on the subject of continuous renal replacement therapy. Dr. Uchino has no conflicts to declare. Dr. Hoste has received fees for speaking from Alexion and Astute Medical, and Research Grant support from Bellco. Dr. Gaudry has received educational grants from Xenios.

Additional information

Take-home message: Renal replacement therapy (RRT) prescription and delivery are not standardized and many aspects of therapy are not supported by high-quality evidence, despite publication of rigorous clinical practice guidelines. In this concise review, we summarize new knowledge and recent advances for the provision of RRT for critically ill patients with acute kidney injury.

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Bagshaw, S.M., Darmon, M., Ostermann, M. et al. Current state of the art for renal replacement therapy in critically ill patients with acute kidney injury. Intensive Care Med 43, 841–854 (2017). https://doi.org/10.1007/s00134-017-4762-8

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  • DOI: https://doi.org/10.1007/s00134-017-4762-8

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