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Acute Kidney Injury and Renal Replacement Therapy

Last Updated: June 11, 2020

Recommendations

  • For critically ill patients with COVID-19 who have acute kidney injury (AKI) and who develop indications for renal replacement therapy (RRT), the COVID-19 Treatment Guidelines Panel (the Panel) recommends continuous renal replacement therapy (CRRT), if available (BIII).
  • If CRRT is not available or not possible due to limited resources, the Panel recommends prolonged intermittent renal replacement therapy (PIRRT) rather than intermittent hemodialysis (IHD) (BIII).

Rationale

AKI that requires RRT occurs in approximately 22% of patients with COVID-19 who are admitted to the intensive care unit.1 Evidence pertaining to RRT in patients with COVID-19 is scarce. Until additional evidence is available, the Panel suggests using the same indications for RRT in patients with COVID-19 as those used for other critically ill patients.2

RRT modalities have not been compared in COVID-19 patients; the Panel’s recommendations are motivated by the desire to minimize the risk of viral transmission to health care workers. The Panel considers CRRT to be the preferred RRT modality. CRRT is preferable to PIRRT because medication dosing for CRRT is more easily optimized and CRRT does not require nursing staff to enter the patient’s room to begin and end dialysis sessions. CRRT and PIRRT are both preferable to IHD because neither requires a dedicated hemodialysis nurse. Peritoneal dialysis has also been used during surge situations in patients with COVID-19.

In situations where there may be insufficient CRRT machines or equipment to meet demand, the Panel advocates performing PIRRT instead of CRRT, and then using the machine for another patient after appropriate cleaning.

References

  1. Richardson S, Hirsch JS, Narasimhan M, et al. Presenting characteristics, comorbidities, and outcomes among 5,700 patients hospitalized with COVID-19 in the New York City area. JAMA. 2020;323(20):2052-2059. Available at: https://www.ncbi.nlm.nih.gov/pubmed/32320003.
  2. American Society of Nephrology. Recommendations on the care of hospitalized patients with COVID-19 and kidney failure requiring renal replacement therapy. March 21, 2020. Available at: https://www.asn-online.org/g/blast/files/AKI_COVID-19_Recommendations_Document_03.21.2020.pdf.