🩺 Renal Replacement Therapy Initiation Indication (CRRT/RRT)
Renal replacement therapy (RRT) initiation and modality decision in acute kidney injury, separating emergent indications from trend-based timing.
Renal Replacement Therapy Initiation Indication (CRRT/RRT)
Refractory hyperkalemia (K > 6.5 or rapidly rising, hard to control medically)
Refractory severe metabolic acidosis (pH < 7.1)
Refractory volume overload/pulmonary edema (diuretic-resistant)
Uremic symptoms (encephalopathy/pericarditis/bleeding) or severe azotemia
Dialyzable toxin/drug poisoning (e.g. lithium, methanol, ethylene glycol, salicylate)
Hemodynamically unstable (needs vasopressors/brain injury/raised ICP)
When to use
Use to identify emergent RRT indications and to choose between continuous (CRRT) and intermittent (IHD) modalities based on hemodynamics.
How it works
Any emergent indication (refractory hyperkalemia, severe acidosis pH < 7.1, refractory volume overload, uremic complications/severe azotemia, dialyzable poisoning) initiates RRT; without these, decide early vs late by trends. CRRT preferred when hemodynamically unstable/brain-injured.
Key points
- Do not apply chronic-CKD BUN/creatinine thresholds to the critically ill; emergent indications and overall trajectory drive timing (original synthesis · not guideline verbatim).
- Trials of early vs delayed initiation (AKIKI, IDEAL-ICU, STARRT-AKI) have not shown consistent benefit to routine early start.
- CRRT offers smoother hemodynamics and ICP control; IHD corrects hyperkalemia faster in stable patients.
References
- KDIGO Clinical Practice Guideline for AKI. Kidney Int Suppl 2012.
- STARRT-AKI Investigators. N Engl J Med 2020.
Decision support for licensed clinicians only; not a substitute for clinical judgement, diagnosis or local protocols.