Treatment of acute kidney injury: an update on the management of renal replacement therapy

PURPOSE OF REVIEW: Renal replacement therapy remains the cornerstone of management for the patient with severe acute kidney injury. Although the technology for providing renal replacement therapy has markedly advanced over the past few decades, fundamental issues regarding its management, including timing of initiation, selection of modality and dosing of therapy, remain unresolved. RECENT FINDINGS: Although several retrospective and observational studies of the timing of initiation of renal replacement therapy have suggested improved survival with early initiation of treatment, the design of these studies does not allow definitive conclusions. Recent randomized trials have not demonstrated any benefit with regard to survival or recovery of renal function with continuous renal replacement therapy compared with intermittent hemodialysis. Increased intensity of renal support appears to be associated with improved survival; however more definitive studies are ongoing. SUMMARY: The optimal management of renal replacement therapy in patients with acute kidney injury remains uncertain. Appropriately designed studies evaluating timing of initiation of therapy need to be undertaken. Current data suggest that modality of therapy does not impact outcome. More intensive renal support may be associated with improved outcomes; however several large randomized controlled trials assessing this question are ongoing.