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Continuous renal replacement therapy: recent advances and future research

Nature Reviews Nephrology volume 6, pages 521–529 (2010)Cite this article

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Abstract

Continuous renal replacement therapy (CRRT) is the preferred treatment for acute kidney injury (AKI) in intensive care units (ICUs) throughout much of the developed world. Despite its widespread use, however, no formal proof exists that patient outcomes are improved when CRRT is used in preference to intermittent hemodialysis (IHD). In addition, controversy and center-specific practice variation in the clinical application of CRRT continues, owing to a lack of randomized multicenter studies of both CRRT and IHD providing level 1 data to inform clinical practice. Now, however, the publication of results from the Veterans Affairs/National Institutes of Health Acute Renal Failure Trial Network (ATN) study and the Randomized Evaluation of Normal versus Augmented Level Renal Replacement Therapy (RENAL) trial have provided an unparalleled quantity of information to guide clinicians. These pivotal trials investigated different intensities of CRRT in the ICU and provided level 1 evidence that effluent flow rates >25 ml/kg per hour do not improve outcomes in patients in the ICU. In this Review, we discuss the background and results of the ATN and RENAL trials and the emerging consensus that CRRT is the most appropriate treatment for AKI in vasopressor-dependent patients in the ICU. Finally, we describe the remaining controversies regarding the use of CRRT and the questions that remain to be answered.

Key Points

  • Continuous renal replacement therapy (CRRT) is now the leading form of renal replacement therapy for acute kidney injury (AKI) in intensive care units (ICUs) worldwide

  • Practice variation in the application of CRRT remains considerable owing to the absence of clear evidence-based guidelines

  • Two large, multicenter, randomized controlled trials have now established that increasing the dose of CRRT above an effluent flow rate of 25 ml/kg per hour is not beneficial

  • CRRT is now widely accepted as the most appropriate therapy for vasopressor-dependent patients who require renal replacement therapy for AKI in the ICU

  • A number of aspects of CRRT require further research, particularly the optimal threshold and timing of CRRT

  • Factors such as local experience and cost will probably continue to determine choice of therapy in different regions

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  1. Department of Intensive Care, Austin Health, 145 Studley Road, Heidelberg, 3084, Vic, Australia

    John R. Prowle & Rinaldo Bellomo

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J. R. Prowle wrote the article and both authors contributed equally to researching data for the article, discussing the content, and reviewing and/or editing the manuscript before submission.

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Correspondence to Rinaldo Bellomo.

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Competing interests

R. Bellomo was lead author and principal investigator of the Randomized Evaluation of Normal versus Augmented Level (RENAL) Replacement Therapy Study. He has received consulting fees from Gambro Biosite, Abbott Diagnostics, and Philips Medical Systems, and grant support from Fresenius Kabi, Bard, Pfizer, and Gambro. For the RENAL study, Gambro provided Hemosol dialysate® and replacement fluids at a favorable price. J. R. Prowle declares no competing interests.

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Prowle, J., Bellomo, R. Continuous renal replacement therapy: recent advances and future research. Nat Rev Nephrol 6, 521–529 (2010). https://doi.org/10.1038/nrneph.2010.100

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