CHEST Guidelines-Continuous-Renal-Replacement-Therapy_2018

Continuous-Renal-Replacement-Therapy_2018_chest

Pdf Summary

Continuous Renal Replacement Therapy (CRRT) is a key method used to support critically ill patients with acute kidney injury (AKI), particularly those who are hemodynamically unstable. CRRT includes techniques like continuous venovenous hemofiltration (CVVH), continuous venovenous hemodialysis (CVVHD), and continuous venovenous hemodiafiltration (CVVHDF), which differ in their mechanisms of solute clearance – convection for CVVH, diffusion for CVVHD, and a combination for CVVHDF.<br /><br />Indications for the initiation of renal replacement therapy (RRT) include volume overload, severe metabolic acidosis, critical electrolyte disturbances, overt uremic symptoms, and persistent or progressive AKI. Despite CRRT being seen as beneficial in fluid management and achieving negative fluid balance, especially in patients with liver failure or brain injury, evidence suggests no significant survival advantage over intermittent hemodialysis (IHD) or prolonged intermittent renal replacement therapy (PIRRT).<br /><br />CRRT uses pump-driven venovenous extracorporeal circuits, which have largely replaced the initial arteriovenous methods due to improved safety and efficiency. The decision to start RRT is complex, often involving the management of kidney failure’s complications and considering factors like patient-specific conditions and current RRT modalities. Such decisions also encompass ethical issues, including patient prognosis and alternative life-sustaining treatments.<br /><br />Using CRRT involves the management of variables such as anticoagulation, typically with heparin or citrate, which is crucial but complicated by risks like bleeding or electrolyte and acid-base imbalances. Drug dosing during CRRT also requires adjustments for factors like non-renal clearance and changing pharmacokinetics. Finally, CRRT's effectiveness and integration with other care aspects are continually evolving, necessitating ongoing assessment and adaptation of protocols based on the latest evidence and patient-specific needs.

Keywords

Continuous Renal Replacement Therapy

CRRT

acute kidney injury

AKI

hemodynamically unstable

renal replacement therapy

RRT

solute clearance

anticoagulation

pharmacokinetics