Continuous Renal Replacement Therapy (CRRT) Guidelines

Introduction to CRRT

The American College of Physicians recommends CRRT as an extracorporeal blood purification therapy that runs continuously to substitute for impaired kidney function by removing excess fluid and retained solutes through a combination of diffusion, convection, ultrafiltration, and adsorption 1

The American Society of Nephrology suggests placing an uncuffed nontunneled dialysis catheter using ultrasound guidance, with the right internal jugular vein as the first choice, then femoral vein, then left internal jugular vein, and subclavian vein as the last resort 3
The Kidney International journal recommends using a blood pump to drive blood through the circuit at controlled rates, unlike older arteriovenous systems that relied on patient blood pressure 2

The American College of Chest Physicians recommends using regional citrate anticoagulation as first-line therapy for patients without contraindications to citrate 3
The Praxis Medical Insights guideline suggests avoiding subclavian veins due to increased risk of thrombosis and late stenosis 3, 4

The Kidney International journal recommends using diffusion as the primary solute removal mechanism, with dialysate flowing countercurrent to blood flow at 1-2 L/hour, and does not routinely require replacement fluid administration 2
The Praxis Medical Insights guideline suggests prescribing 20-25 mL/kg/h of effluent volume, with a standard surface area of 0.9-1.5 m² for most adults 3, 4

The American Society of Nephrology recommends using bicarbonate-buffered (not lactate-buffered) dialysate solution for all patients, especially those with circulatory shock, liver failure, or lactic acidemia 3
The Praxis Medical Insights guideline suggests calculating net fluid removal based on patient's volume status and hemodynamic tolerance, with a target net ultrafiltration rate of 100 mL/hour (adjust based on volume status) 3, 4

The American College of Physicians recommends using a dialyzer with biocompatible membrane material, with a standard surface area of 0.9-1.5 m² for most adults 3
The Kidney International journal suggests monitoring filter performance, electrolyte balance, acid-base status, and fluid balance closely, and adjusting the prescription as needed 2, 3

The Praxis Medical Insights guideline recommends CVVHD for hyperammonemia management due to higher ammonia clearance rates compared to CVVH, and suggests that CVVH removes middle and large molecular weight solutes more efficiently, though this has not proven to improve clinical outcomes 4