Renal Replacement Therapy for Critically Ill Patients with Acute Kidney Injury

Primary Recommendations

The Kidney Disease: Improving Global Outcomes (KDIGO) guidelines, endorsed by the Kidney Disease Outcomes Quality Initiative (KDOQI), suggest using Continuous Renal Replacement Therapy (CRRT) rather than standard intermittent hemodialysis for hemodynamically unstable patients (Grade 2B recommendation) 1
The American College of Cardiology recommends CRRT as the preferred modality for hemodynamically unstable critically ill patients with acute kidney injury, but SLED is an acceptable alternative when CRRT is unavailable or resource-constrained 1, 2
The Surviving Sepsis Campaign suggests either CRRT or intermittent Renal Replacement Therapy (RRT), with CRRT preferred for facilitating fluid balance management in hemodynamically unstable septic patients 3, 4

The KDOQI Work Group states that prolonged intermittent RRT modalities (PIRRT/SLED) are reasonable alternatives to CRRT in hemodynamically unstable adult patients, though additional clinical research is needed to compare outcomes and cost-effectiveness 2
CRRT remains the preferred choice in specific high-risk scenarios, such as acute brain injury with increased intracranial pressure or cerebral edema, and severe hemodynamic instability requiring continuous fine-tuning 1, 5, 2, 7
CRRT allows for continuous adjustment of intravascular volume and better management of severe fluid overload 8

Deliver effluent volume of 20-25 mL/kg/hour as the standard dose for CRRT 1, 7, 9
Use regional citrate anticoagulation as first-line in patients without contraindications for CRRT 1, 7, 9
Monitor delivered versus prescribed dose frequently and adjust iteratively for CRRT 7
Avoid subclavian vein access and use right internal jugular as first choice, then femoral, then left internal jugular, with subclavian as last resort 1, 7, 9