This algorithm will not specifically address additional key issue

This algorithm will not specifically address additional key issues in the delivery of renal support, such as RRT modality (continuous versus intermittent), mode (convection versus diffusion) and dose delivery [17-20]. Importantly, the algorithm is also intended to provide a starting point for further prospective evaluation to understand the ideal time/circumstances for when to initiate RRT that could, in due course, promote higher quality of patient care and improved clinical outcomes.Figure 1Algorithm for initiation of renal replacement therapy in critically ill patients. *’Optimized resuscitation’ of the kidney should also include discontinuation/withholding nephrotoxic medications and anti-hypertensive medications that may exacerbate kidney …

Algorithm for initiation of renal replacement therapy in critically ill patientsThe first priority after a patient is admitted to ICU is determination of whether there are absolute indications and/or emergent need for RRT. A summary of proposed absolute indications for RRT initiation, based on consensus, is presented in Table Table22[16]. It is important, however, to recognize that RRT initiation in these circumstances can largely be viewed as ‘rescue therapy’ where delays may have deleterious consequences for the patient. Moreover, these indications are largely adapted from ‘classic conventional’ indications for RRT in end-stage kidney disease, wherein the main objective is alleviation of uremic complications.

Table 2A summary of absolute or ‘rescue therapy’ indications for initiation of renal replacement therapy in critically ill patientsSince AKI is common in critical illness, in the absence of absolute indications for RRT, the next logical step is to determine whether patients have AKI. In a multi-center multinational study, Uchino and colleagues [4] found AKI occurred in 5 to 6% of all ICU admissions, with 70% of these eventually receiving RRT. Recent data indicate the incidence of AKI is rising [21-23]. Historically, however, establishing incidence estimates of AKI has been problematic due to the lack of a standardized definition. Fortunately, a consensus-driven classification scheme for AKI, the RIFLE criteria (and modified AKIN criteria), has been recently proposed, which represents a noteworthy advance for clinical practice and research in AKI [24,25].

The RIFLE criteria have been validated and proven robust for clinically relevant outcomes in patients with AKI across numerous studies [3,5,26-29]. Epidemiologic studies of AKI, when defined by the RIFLE criteria, have shown that 11 to 67% of ICU patients may develop AKI during their illness course [29].The RIFLE/AKIN criteria and initiation of renal replacement therapyThe Brefeldin_A RIFLE criteria were initially developed to standardize the diagnosis, classify the severity and monitor progression of AKI.

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