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2025 PACUPrep BCCCP Preparatory Course Renal Replacement Therapies (RRT) Renal Replacement Therapies in Critical Care

Lesson 20, Topic 5

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Renal Replacement Therapies in Critical Care

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RRT De-escalation, Transition, and Care Alignment

De-escalation, Transition, and Care Alignment in Renal Replacement Therapy

Learning Objective

Create a plan for Renal Replacement Therapy (RRT) de-escalation, modality transition, and alignment with patient-centered goals.

1. Introduction and Scope

Safely stopping or down-shifting Renal Replacement Therapy (RRT) as renal function recovers is crucial for minimizing complications, shortening Intensive Care Unit (ICU) stay, and conserving resources. The processes of de-escalation (often termed liberation from RRT) and transition (e.g., from continuous RRT (CRRT) to prolonged intermittent RRT (PIRRT) or intermittent hemodialysis (IHD)) demand objective criteria and robust multidisciplinary coordination.

Rationale and Impact

Rationale: The primary goal is to avoid prolonged and unnecessary extracorporeal support once sufficient native kidney clearance returns. This helps reduce risks associated with RRT, including infection, bleeding, electrolyte disturbances, and patient deconditioning.
Impact: Studies focusing on early liberation from RRT have demonstrated potential benefits such as reduced ICU length of stay and lower healthcare costs, without an associated increase in mortality rates.

Key Pearl: Protocolized De-escalation

Implementing protocolized de-escalation strategies that utilize objective criteria, such as urine output thresholds and laboratory markers, can significantly reduce unnecessary exposure to RRT and its associated complications.

2. Clinical and Laboratory Criteria for Renal Recovery

Assessing readiness for RRT liberation hinges on evidence of sustained improvement in urine output, favorable trends in solute markers (like creatinine and urea), stable acid-base and electrolyte balance, and potentially the use of risk stratification tools. A holistic view is essential.

Key Indicators of Recovery

Urine Output: A sustained urine output of ≥0.5 mL/kg/hour for at least 6–12 hours, ideally while off diuretic therapy, is a strong indicator of recovering glomerular filtration rate (GFR).
Serum Creatinine/Urea: A consistent downward trend in serum creatinine and urea levels suggests improving renal clearance. However, it’s important to consider a potential lagging effect, especially in highly catabolic patients.
Acid-Base and Electrolyte Stability: Resolution of metabolic acidosis and normalization or stabilization of key electrolytes (e.g., potassium <5 mEq/L, phosphate >2.5 mg/dL, magnesium >1.5 mg/dL) are crucial.
Adjunctive Biomarkers (Investigational): Novel biomarkers such as Neutrophil Gelatinase-Associated Lipocalin (NGAL) and Cystatin C are being investigated for their potential to provide earlier signals of renal recovery, though their routine use is not yet standard.
Risk Stratification Tools: Tools like the Kidney Failure Risk Equation (KFRE) can aid in predicting the likelihood of sustained renal function post-liberation, helping to frame discussions and decisions.
Composite Assessment: Decisions should not be based on isolated parameters. It is vital to integrate overall hemodynamic stability (e.g., Mean Arterial Pressure (MAP), vasopressor requirements), volume status, and the patient’s clinical trajectory before attempting a trial off RRT.

Key Pearl: Holistic Assessment

Avoid relying on a single parameter for liberation decisions. A comprehensive approach that combines urine output data, laboratory trends, and overall clinical status is essential for ensuring safe and successful liberation from RRT.

3. Modality Transition Strategies

Transitioning patients from continuous RRT (CRRT) to intermittent therapies like Prolonged Intermittent RRT (PIRRT) or Intermittent Hemodialysis (IHD) requires careful consideration of hemodynamic stability, meticulous pre-transition planning, and appropriate anticoagulation adjustments.

Hemodynamic Criteria for Transition

Sustained Mean Arterial Pressure (MAP) ≥65 mmHg with minimal or no vasopressor support for at least 6 hours.
Stable Central Venous Pressure (CVP) / Central Venous Oxygen Saturation (ScvO₂) and absence of significant blood pressure fluctuations during any CRRT downtime or filter changes.

Selecting the Appropriate Intermittent Modality

PIRRT (Prolonged Intermittent RRT): Typically involves 6–12 hour sessions, offering moderate solute and fluid clearance. It is often better tolerated in patients with borderline hemodynamic stability compared to conventional IHD.
IHD (Intermittent Hemodialysis): Consists of shorter 3–4 hour sessions, providing rapid solute and fluid removal. This modality generally requires more robust hemodynamic stability due to faster fluid shifts.

Protocol Checklist for Transition

Confirm euvolemia or only mild fluid overload (target ±0.5 L) based on daily fluid balance assessments and clinical examination.
If using regional citrate anticoagulation (RCA) for CRRT, discontinue it at least 2 hours before the planned intermittent session. Switch to systemic heparin if anticoagulation is still deemed necessary for the intermittent modality.
Set appropriate initial parameters for the chosen intermittent session:
- Blood flow rate: typically 150–200 mL/min for PIRRT.
- Dialysate flow rate: typically 100–300 mL/min.
Plan a conservative ultrafiltration (UF) goal, especially for the first session (e.g., ≤1 Liter per session initially, adjusted based on tolerance).
Implement diligent post-session monitoring: vital signs every 15 minutes for the first hour, then as clinically indicated. Check basic metabolic panel (BMP) at 2 hours and 6 hours post-session to assess for rebound electrolyte changes or inadequate clearance.

Anticoagulation Overview for RRT

Comparison of Anticoagulation Strategies in RRT
Anticoagulant Strategy	Mechanism of Action	Monitoring Parameters	Common Pitfalls & Considerations
Regional Citrate Anticoagulation (RCA)	Citrate chelates ionized calcium (Ca²⁺) within the extracorporeal circuit, preventing clot formation. Citrate is metabolized in the liver and muscle to bicarbonate.	Pre-filter and post-filter ionized Ca²⁺ levels. Total systemic Ca²⁺ to ionized Ca²⁺ ratio. Adjust citrate infusion rate to maintain post-filter ionized Ca²⁺ typically between 0.25–0.35 mmol/L.	Risk of citrate accumulation (“citrate lock”) in patients with severe liver failure. Potential for metabolic alkalosis (due to bicarbonate generation) or systemic hypocalcemia if not managed carefully.
Systemic Heparin	Unfractionated heparin potentiates antithrombin III, inhibiting thrombin and Factor Xa, thus preventing clot formation throughout the circuit and patient.	Activated Partial Thromboplastin Time (aPTT), typically targeting 60–80 seconds, or anti-Factor Xa levels, targeting 0.3–0.7 IU/mL.	Increased systemic bleeding risk. Potential for Heparin-Induced Thrombocytopenia (HIT). Requires regular monitoring and dose adjustments.
No Anticoagulation	Relies on adequate blood flow rates and sometimes saline flushes to maintain circuit patency.	Visual inspection of the circuit for clotting. Circuit pressures.	Generally results in shorter filter lifespan. May require frequent saline flushes (e.g., every 30–60 minutes), which can contribute to fluid overload. Often reserved for patients with very high bleeding risk.

Key Pearl: Anticoagulation in Transition

Effective transition planning must incorporate a clear anticoagulation strategy. This is vital to prevent premature filter clotting during the new modality or to avoid metabolic derangements that can occur if, for example, citrate is not appropriately discontinued or managed during the switch.

4. Multidisciplinary Goals-of-Care Discussions

Engaging a multidisciplinary team is fundamental to align RRT plans with patient values, preferences, and overall prognosis. This collaborative approach should involve nephrology, critical care, pharmacy, nursing, nutrition, palliative care, and ethics consultation when appropriate.

Team Roles in RRT Decision-Making

Nephrology: Leads modality selection (CRRT, PIRRT, IHD), timing of initiation/de-escalation, and vascular access planning.
Critical Care: Manages overall patient stability, hemodynamics, and integrates RRT into the broader critical care plan.
Pharmacy: Crucial for drug dosing adjustments across different RRT modalities and managing anticoagulation.
Nursing: Provides direct patient care, monitors the RRT circuit, manages alarms, and supports early mobilization efforts.
Nutrition: Assesses and manages nutritional needs, considering solute and protein losses during RRT.
Palliative Care/Ethics: Offers expertise in discussing complex goals of care, managing symptoms, interpreting advance directives, and exploring conservative care options when RRT may not align with patient goals or prognosis.

Utilizing Prognostic Tools

Objective prognostic tools can help frame realistic outcome discussions:

SOFA (Sequential Organ Failure Assessment) Score: Provides an estimate of organ dysfunction severity and mortality risk.
Frailty Indices: Assess baseline functional status, which can impact recovery and tolerance of intensive therapies.
KFRE (Kidney Failure Risk Equation): Can help predict the risk of progression to end-stage kidney disease.

Shared Decision-Making Process

Openly discuss the potential benefits versus burdens of initiating, continuing, or withdrawing RRT.
Ensure advance directives, code status, and specific RRT preferences are clearly documented and accessible in the patient’s chart.

Communication Workflows

Schedule structured family meetings regularly (e.g., every 48–72 hours or as needed) to provide updates and discuss goals.
Utilize standardized templates for documenting goals-of-care discussions to ensure clarity and consistency.

Key Pearl: Iterative Communication

Early and iterative goals-of-care conversations, involving the patient (if able), family, and the multidisciplinary team, are essential for improving the alignment of RRT with patient-centered outcomes and values throughout the course of critical illness.

5. Pharmacoeconomic Considerations

Different RRT modalities (CRRT, PIRRT, IHD) have varying cost implications related to supplies, specialized fluids, anticoagulants, and staffing requirements. Strategic and timely transition between modalities can lead to substantial cost savings without compromising patient care.

Key Cost Drivers in RRT

CRRT: Associated with continuous filter/cartridge replacement, high volumes of pre-packaged replacement and dialysate fluids, expenses related to citrate anticoagulation (if used), and often requires a higher nursing intensity (e.g., 1:1 or 1:2 nurse-to-patient ratio).
PIRRT: Involves intermediate supply costs compared to CRRT, generally with lower nursing intensity than continuous therapies.
IHD: Typically has minimal disposable costs per session (dialyzer, bloodlines) and allows for shared nursing time across multiple patients in a dialysis unit.

Value Metrics in RRT

Assessing the value of RRT strategies extends beyond direct costs:

Quality-Adjusted Life Years (QALYs): A measure of disease burden, including both the quality and the quantity of life lived.
ICU and Hospital Length of Stay: Shorter stays reduce overall healthcare expenditure and risks of hospital-acquired complications.
Resource Utilization per Unit of Clearance: Comparing the cost-effectiveness of different modalities in achieving desired solute and fluid removal.

Editor’s Note: Insufficient source material was provided for a detailed 72-hour cost comparison across CRRT, PIRRT, and IHD. A comprehensive analysis in this section would typically include:

Specific per-session or per-day costs for cartridges/filters and fluids for each modality.
Detailed breakdown of nursing hours per modality and associated salary-adjusted expenses.
Comparative unit costs for anticoagulants (e.g., citrate solution vs. heparin vials and monitoring).

Key Pearl: Standardize Transition Triggers

Standardizing objective triggers for transitioning from more resource-intensive modalities like CRRT to less intensive ones (PIRRT/IHD) can help prevent unnecessary CRRT days, thereby optimizing resource allocation and realizing potential cost savings.

6. Case-Based Algorithms and Checklists

Utilizing stepwise algorithms and checklists can help operationalize decisions regarding RRT liberation and modality transition, promoting consistency and adherence to best practices. These tools should be adapted to local institutional protocols and resources.

Algorithm 1: RRT Liberation Readiness Assessment

Start: Assess Liberation Readiness

Urine Output ≥0.5 mL/kg/h
for 6-12h (off diuretics)?

Yes No

Downward Creatinine/
Urea Trend?

Yes No

Normal Acid-Base &
Electrolytes?

Yes No

Trial Off RRT

If any “No” above:

Continue CRRT,
Reassess Daily

Figure 1: Simplified algorithm for assessing RRT liberation readiness. Hemodynamic stability (MAP ≥65 mmHg, minimal vasopressors) is a crucial concurrent criterion before proceeding to a trial off RRT.

Checklist 2: RRT Modality Transition Protocol (CRRT to PIRRT/IHD)

Confirm Hemodynamic Stability
(MAP ≥65, min. vasopressors)

Verify Fluid Balance
(Euvolemia or mild overload)

Adjust Anticoagulation
(e.g., Stop citrate, plan heparin)

Select PIRRT/IHD Parameters
(Session length, BFR, DFR, UF goal)

Monitor During & Post-Session
(Vitals, labs, patient tolerance)

Figure 2: Checklist for transitioning from CRRT to PIRRT or IHD.

Economic Impact Scenario (Outline)

A detailed economic analysis would compare the costs over a defined period (e.g., 72 hours) for a patient on CRRT versus an equivalent period where the patient is transitioned to PIRRT or IHD earlier. This comparison would include:

Costs of consumables (filters, fluids).
Anticoagulation costs.
Nursing staff time and associated costs.
Impact on overall ICU length of stay and related expenses.

(Refer to Section 5 for further discussion on pharmacoeconomic drivers.)

7. Key Pearls Summary and Future Directions

The de-escalation and transition of RRT are critical phases in the care of patients recovering from acute kidney injury. Standardized approaches, multidisciplinary collaboration, and patient-centered goals are paramount.

Summary of Key Pearls

Protocolized de-escalation using objective criteria reduces unnecessary RRT exposure.
A holistic assessment (urine output, labs, clinical status) is vital for safe liberation, not reliance on single parameters.
Transition planning must meticulously address anticoagulation to prevent complications.
Early, iterative goals-of-care conversations align RRT with patient-centered outcomes.
Standardizing transition triggers can optimize resource use and yield cost savings.

Future Directions

Development and validation of standardized, evidence-based liberation criteria are urgently needed to reduce practice variability and improve outcomes.
Prospective clinical trials should focus on validating biomarker-guided weaning strategies and optimal protocols for modality transition.
Integration of real-world data and machine learning may support the continuous refinement of RRT pathways and personalized decision-making.
Further research is needed to clearly define economic thresholds at which transitioning between RRT modalities yields maximal clinical and financial value.

References

KDIGO. KDIGO 2024 Clinical Practice Guideline for CKD Evaluation and Management. Kidney Int. 2024;105(4S):S117–S314.
Gautam SC, Lim J, Jaar BG, et al. Complications Associated with Continuous RRT. Kidney360. 2022;3:1980–1990.
Kashani K, Rosner MH, Haase M, et al. Quality improvement goals for acute kidney injury. Clin J Am Soc Nephrol. 2019;14(7):941–953.
Zarbock A, Kullmar M, Kindgen-Milles D, et al. Regional citrate vs systemic heparin anticoagulation in CRRT. JAMA. 2020;324(15):1629–1639.
Pistolesi V, Zeppilli L, Fiaccadori E, et al. Hypophosphatemia in CRRT patients. J Nephrol. 2019;32(6):895–908.
Mayer KP, Joseph-Isang E, Robinson LE, et al. Physical rehabilitation during CRRT. Crit Care Med. 2020;48(8):e1112–e1120.
Awdishu L, Bouchard J. How to optimize drug delivery in RRT. Semin Dial. 2011;24(2):176–182.

2025 PACUPrep BCCCP Preparatory Course

Pulmonary

Participants 432

Renal Replacement Therapies in Critical Care

De-escalation, Transition, and Care Alignment in Renal Replacement Therapy

Learning Objective

1. Introduction and Scope

Rationale and Impact

2. Clinical and Laboratory Criteria for Renal Recovery

Key Indicators of Recovery

3. Modality Transition Strategies

Hemodynamic Criteria for Transition

Selecting the Appropriate Intermittent Modality

Protocol Checklist for Transition

Anticoagulation Overview for RRT

4. Multidisciplinary Goals-of-Care Discussions

Team Roles in RRT Decision-Making

Utilizing Prognostic Tools

Shared Decision-Making Process

Communication Workflows

5. Pharmacoeconomic Considerations

Key Cost Drivers in RRT

Value Metrics in RRT

6. Case-Based Algorithms and Checklists

Algorithm 1: RRT Liberation Readiness Assessment

Checklist 2: RRT Modality Transition Protocol (CRRT to PIRRT/IHD)

Economic Impact Scenario (Outline)

7. Key Pearls Summary and Future Directions

Summary of Key Pearls

Future Directions

References