How to prescribe and troubleshoot continuous renal replacement therapy: A case-based review

Abstract

Continuous renal replacement therapy (CRRT) is the preferred dialysis modality for solute management, acid-base stability, and volume control in critically ill patients with acute kidney injury (AKI) in the intensive care unit (ICU). CRRT offers multiple advantages over conventional hemodialysis in the critically ill population such as greater hemodynamic stability, better fluid management, greater solute control, lower bleeding risk and a more continuous (physiologic) approach of kidney support. Despite its frequent use, several aspects of CRRT delivery are still not fully standardized or do not have solid evidence-based foundations. In this manuscript, we provide a case-based review and recommendations of common scenarios and interventions encountered during the provision of CRRT to critically ill patients. Specific focus is made on initial prescription, CRRT dosing, and adjustments related to severe hyponatremia management, concomitant extracorporeal membrane oxygenation support, dialysis catheter placement, use of regional citrate anticoagulation and antibiotic dosing. This case-driven simulation is made as the clinical status of the patient evolves and is based on step-wise decisions made during the care of this patient according to specific patient's needs and the logistics available at the corresponding institution.