Step 12: Assess recovery of renal function and try to wean from RRT

•Urine output: increasing urine output especially after an oliguric phase and when the patient has not been on diuretics is considered the best sign of recovery.

•Change of urea or creatinine levels from postdialysis levels, when they remain steady or decline in between dialysis session, might be particularly helpful in nonoliguric patients.

•Trend of biomarkers like NGAL (neutrophil-gelatinase-associated lipocalin) may be helpful in indicating renal recovery. NGAL is not removed by dialysis.

Suggested Reading

1.Brochard L, Abroug F, ATS/ERS/ESICM/SCCM/SRLF Ad Hoc Committee on Acute Renal Failure. An official ATS/ERS/ESICM/SCCM/SRLF statement: Prevention and management of acute renal failure in the ICU patient: an international consensus conference in intensive care medicine. Am J Respir Crit Care Med. 2010;181(10):1128–55.

The jury recommended the use of newly described definitions.

2.Ricci Z, Ronco C. Dose and efficiency of renal replacement therapy: continuous renal replacement therapy versus intermittent hemodialysis versus slow extended daily dialysis. Crit Care Med. 2008;36(4 Suppl):S229–37.

Some broad concepts and a few suggestions for renal replacement therapy prescription derived from current evidence and from the available experience are given.

3.Palevsky PM. Indications and timing of renal replacement therapy in acute kidney injury. Crit Care Med. 2008;36(4 Suppl):S224–8.

Existing data on timing of initiation of renal replacement therapy in acute kidney injury that guide current clinical practice are summarized, and issues that need to be addressed in future clinical trials are discussed.

4.Doshi M, Murray PT. Approach to intradialytic hypotension in intensive care unit patients with acute renal failure. Artif Organs. 2003;27(9):772–80.

Intradialytic hypotension (IDH) is caused by the interaction of dialysis-dependent and dialysisindependent factors. An approach to the prevention and management of IDH in critically ill ARF patients, which minimizes hypovolemic, cardiogenic, and vasodilatory insults by optimizing fluid removal, cardiac function, and vascular contractility, is proposed

5.Bellomo R, Ronco C. Indications and criteria for initiating renal replacement therapy in the intensive care unit. Kidney Int Suppl. 1998;66:S106–9.

Even though there are several time-honored indications for initiating dialytic therapy in patients with near end-stage renal failure, such indications may not apply to the management of acute renal failure (ARF).

Websites

1.www.ADQI.net

Homepage for ADQI network on acute kidney injury

2.www.crrtonline.com

Practical aspects of managing CRRT, including nursing perspective

3.www.asn-online.org

American Society of Nephrology webpage with information on various aspects of AKI