Four Modes Of Kidney Replacement Therapy For Acute Kidney Injury

In general, severe acute kidney injury (AKI) necessitates renal replacement therapy (RRT). Intermittent hemodialysis, peritoneal dialysis, continuous renal replacement therapy (CRRT), and extended intermittent renal replacement therapy are four common modes of RRT. However, in clinical practice, physicians often worry about which RRT mode should be used to treat AKI patients.

Click to cistanche tubulosa beneficial for kidney disease

1. Characteristics of the 4 modes of renal replacement therapy

When choosing RRT for AKI, the main purpose of treatment, the patient's metabolic disorder, the degree of volume overload, and the stability of hemodynamics should be considered first, and then combined with the technical characteristics of RRT to make a comprehensive judgment and selection.

01 Intermittent hemodialysis

Intermittent hemodialysis is a traditional hemodialysis method, and it is also a commonly used dialysis method in the treatment of AKI. The duration of dialysis is 3 to 5 hours each time, the blood flow is 200 to 300 ml/min, and the dialysate flow is 300 to 500 ml/min. Heparin, low molecular weight heparin or no anticoagulant can be used for anticoagulant treatment.

Advantages: (1) It can quickly correct water, electrolyte, acid-base balance disorders, and metabolic disorders of water-soluble low molecules; (2) The treatment time is short and has little impact on other treatments and examinations of patients; (3) Anticoagulation can not be used when necessary (4) The cost of treatment is relatively low.

Disadvantages: (1) Hypotension may occur when the fluid is quickly removed; (2) There is a risk of dialysis imbalance and cerebral edema; (3) The technical requirements are many and complicated; (4) Reverse osmosis water treatment equipment and dialysis machines are required, and resources are limited. It cannot be implemented in places and environments with limited or poor medical conditions.

02 Peritoneal Dialysis

In recent years, with the continuous improvement and optimization of peritoneal dialysis technology, more and more clinical studies have shown that the use of peritoneal dialysis in the treatment of AKI can achieve a satisfactory level, whether in the ICU or in the ward [1].

Advantages: (1) Simple operation, no equipment requirements, and can be implemented in primary hospitals; (2) There is basically no need for water and electricity, and it can still be used even in extreme and special environments; (3) No need for extracorporeal circulation, hemodynamics Not affected; (4) No need for systemic anticoagulation, no increased risk of bleeding; (5) It is the most economical treatment mode.

Disadvantages: (1) There are high requirements for the technique of peritoneal dialysis catheter placement; (2) Slow onset, relatively low clearance rate of small molecules, and slow liquid clearance; (3) It can affect the movement of the diaphragm and cause respiratory problems; (4) There may be protein loss; (5) There is a risk of peritonitis; (6) A complete abdominal cavity is required, so it is not suitable for patients undergoing abdominal surgery.

03 CRRT

CRRT refers to a continuous extracorporeal blood purification therapy that takes 24 hours or close to 24 hours to replace the treatment mode of impaired renal function.

Advantages: (1) relatively stable hemodynamics; (2) easy to control fluid balance; (3) slow and continuous removal of toxins; (4) can be combined with other organ support therapy at the same time; (5) does not require water treatment equipment.

Disadvantages: (1) Continuous anticoagulation is required, and the risk of bleeding is relatively high; (2) The patient's activities are limited, which affects other examinations and treatments; (3) It is expensive.

04 Extended Intermittent Renal Replacement Therapy

Advantages: (1) slow solute and fluid clearance, similar to the hemodynamic stability of CRRT; (2) can reduce the use of anticoagulants; (3) shorten the treatment time of patients, which is conducive to other treatments and related examinations .

Disadvantages: (1) Toxin removal is slow; (2) The treatment technique is relatively complicated, requiring dialysis nurses to operate, and stricter electrolyte monitoring is required; (3) Antibiotic doses need to be adjusted, especially for the treatment of patients with multidrug-resistant bacterial infections The above challenges [2].

2. During AKI, 4 modes can be selected

At present, there is still a lot of clinical controversies about which RRT is the best mode for the treatment of AKI. However, from the perspective of patient mortality outcome analysis, there is no significant difference between the four RRT modes. For example, if AKI patients in the ICU use intermittent hemodialysis as initial treatment, renal recovery may be delayed[3]; compared with intermittent hemodialysis, CRRT as initial treatment has no benefit in terms of patient survival or renal recovery, and even May be associated with poorer outcomes in patients with less severe disease [4]; peritoneal dialysis was associated with the shortest duration of renal support and ICU stay; prolonged intermittent renal replacement therapy was associated with the shortest length of stay and days of mechanical ventilation; in There were also no differences between CRRT and intermittent hemodialysis in terms of hypotension or other treatment complications, but there was an increased risk of hypotension and bleeding in the extracorporeal modality compared with peritoneal dialysis.

The series of evidence-based medicine mentioned above all show that these four RRT modes have little difference in the patient's outcome. Therefore, in clinical practice, no matter which mode is chosen, it is reasonable in critically ill patients [5]. Although the selection of these four modes is reasonable clinically, one important principle cannot be ignored, that is, the "principle of personalized medicine".

3. Select key points: Follow the principles of personalized medicine

When patients with AKI choose RRT mode, they should follow the principle of personalized medicine. This is mainly because the need for RRT in AKI patients is dynamic. Ideally, it would be better to have optional equipment with multiple performances. Through accurate monitoring, patients with AKI should be considered in all aspects from the whole process of RRT preparation, prescription, initiation, implementation, program adjustment, and termination of treatment. The condition of the patient, and then carry out personalized treatment, so that the treatment effect and patient prognosis will be better.

In areas with unbalanced economic development, the RRT model for AKI patients is recommended as follows: (1) The application of PD technology in AKI patients should be actively promoted; (2) In ICUs specializing in kidneys and hospitals that have no financial capacity to implement CRRT, ICUs should be constructed. Simple water treatment equipment should be considered to implement extended intermittent renal replacement therapy and intermittent hemodialysis; (3) Appropriate RRT should be implemented in accordance with the guidelines in economically developed areas and large general and teaching hospitals.

Summarize  

In fact, each RRT technique for the treatment of AKI has its own advantages and disadvantages. Intermittent hemodialysis is the most effective in removing fluid and solutes, so it is the most effective treatment for hyperkalemia, hypermetabolic state, and removal of water-soluble toxic substances. The best technology; CRRT is most suitable for patients with unstable hemodynamics and high requirements for body fluid balance; extended intermittent renal replacement therapy combines the advantages of intermittent hemodialysis and CRRT, and is a blood flow therapy that requires inspection and physical therapy during the day The appropriate technique for patients with dynamic instability; peritoneal dialysis is the easiest, safe and cheapest treatment technique among the four techniques, and its advantages are more prominent in extreme environments. Therefore, in different disease states and corresponding environments, AKI patients should adopt the most ideal treatment plan for the specific treatment goals of individual patients, and make adaptive adjustments according to the dynamic changes of the disease, so as to meet the needs of AKI patients at any time, so as to achieve a better Good therapeutic effect.

for more information:ali.ma@wecistanche.com