When To Initiate RRT in the Critically Ill Patient

• Acute kidney injury (AKI) occurs in more than half of critically ill patients admitted to the ICU.
• When and how to initiate renal replacement therapy (RRT) in the critically ill patient remains debated.
• While a strategy of deferred RRT is preferable in many, indications for immediate RRT in patients with AKI include the following:
  • Potassium > 6.5 that is refractory to medical therapy
  • pH < 7.15 that is not responsive to bicarbonate administration
  • Fluid overload (worsening pulmonary edema, P/F ratio < 200 mm Hg) that is refractory to diuretics

References

Barbar SD, Wald R, Quenot JP. Acute kidney injury: when and how to start renal replacement therapy. Intensive Care Med. 2025;51:1172-1175.