RENAL REPLACEMENT

THERAPY IN CRITICAL
CARE
ACUTE KIDNEY INJURY
• Acute renal failure, also known as acute kidney injury (AKI), is defined as
an abrupt (within 48 hours) reduction in kidney function.
• The AKI network defines the reduction in kidney function as the presence
of any one of the following:
a. An absolute increase in serum creatinine of≥ 0.3mg/dl (= 26.4mcmol/L),
b. A percentage increase in serum creatinine of ≥50% (1.5-fold from
baseline),
c. A reduction in urine output (<0.5ml/kg per hour for more than six
hours).

(Baker, 2012)
The initial management of AKI involves:
• treating the underlying cause,
• stopping nephrotoxic drugs
• and ensuring that the patient is euvolaemic, with an adequate mean
arterial blood pressure.

(Baker, 2012)
INDICATIONS FOR RRT
• Acute kidney injury (AKI) with:
a. Fluid overload(unresponsive to diuretics)
b. Hyperkalemia(K > 6.5)
c. Severe metabolic acidosis (pH<7.1)
d. Rapidly climbing urea/creatinine (or urea > 30mmol/L)
e. Symptomatic uraemia: encephalopathy,pericarditis, bleeding,
nausea, pruritus
f. Oliguria/anuria.
(Baker, 2012)
(Baker, 2012)
TYPES OF RRT IN USE IN
INTENSIVE CARE
• Intermittent haemodialysis (IHD)
• Continuous renal replacement therapies (CRRT) :
a. Continuous venovenous haemofiltration (CVVH)
b. Continuous venovenous haemodialysis (CVVHD)
c. Continuous venovenous haemodiafiltration (CVVHDF)
d. Slow continuous ultrafiltration (SCUF)
e. Continuous arteriovenous haemofiltration (CAVHD).
• Hybrid therapies
(Baker, 2012)
DURATION OF TREATMENT
Intermittent (IHD) versus continuous (CRRT)
• Intermittent haemodialysis involves dialysing with higher flow rates
than CRRT for defined periods of time.
• A typical regime is 3-5 hours of dialysis 3 times a week.
• The high flow rates and rapid fall in plasma osmolality mean that it is
only suitable for patients who are cardiovascularly stable.

(Baker, 2012)
• CRRT involves filtering and/or dialysing on a continuous basis.
• It allows better fluid management and creates less haemodynamic
• disturbance, but it is more expensive than IHD and requires
continuous rather than intermittent anticoagulation.
• There is some evidence to suggest that CRRT is superior to IHD in
patients with sepsis, cardiovascular instability or with a head injury.

(Baker, 2012)
WHICH FORM OF RRT SHOULD
WE USE?
The decision about which technique to use depends on:
1. What we want to remove from the plasma
2. the patient`s cardiovascular status
3. the availability of resources

(Baker, 2012)
(Baker, 2012)