Kidney Replacement Therapy (KRT)
Description Medicine treatment Description Acute kidney injury (AKI) may affect 60% of ICU patients with up to two-thirds of these patients going on to require kidney replacement therapy (KRT). LoE: IVb xv KRT is commonly used in critically ill patients to achieve solute clearance, maintain acid-base status, and remove fluid excess. Indications for acute Kidney Replacement Therapy (RRT): Stage 3
Description
Acute kidney injury (AKI) may affect 60% of ICU patients with up to two-thirds of these patients going on to require kidney replacement therapy (KRT).
KRT is commonly used in critically ill patients to achieve solute clearance, maintain acid-base status, and remove fluid excess.
Indications for acute Kidney Replacement Therapy (RRT):
- Stage 3 acute kidney injury deemed unlikely to resolve in the next few days
- Refractory fluid overload
- Clinical features of uraemia (e.g. gastritis, pericarditis, delirium, seizures)
- Life threatening acidosis
- Refractory hyperkalaemia
- Life threatening overdoses requiring KRT removal (e.g. lithium, theophylline, methanol, ethylene glycol, carbamazepine, and valproic acid)
Choice of mode of KRT:
- KRT may be continuous (CKRT) or intermittent (IKRT), and includes sustained low efficiency dialysis (SLED).
- There is no evidence that one method is superior compared to the others.
- CKRT is preferable in patients with hemodynamic instability, acute brain injury, increased intracranial pressure, generalized cerebral oedema, or liver failure.
Medicine Treatment
To reduce circuit hypercoagulability:
- Unfractionated Heparin, 5000 units diluted in 50ml 0.9% sodium chloride (100 units/ml), administered directly into the RRT circuit.
- Initial bolus: 10-20 units/kg.
- Continue running infusion at 5-10 units/kg/hour.
- Monitor using daily Activated Partial Thromboplastin Time (aPTT).
- Maintain aPTT between 45-55 seconds.
OR
- Enoxaparin, SC, 40mg daily
Note:
- Only use heparin if there is no bleeding risk. Use saline flushes if there is a significant risk of bleeding.
Standard Treatment Guidelines and Essential Medicines List for South Africa Adult Hospital _Chapter 23: Adult Critical Care_NEMLC Medicine Recommendations Review Cycle_ 2020_2023