Dialytic treatment for septic patients with acute kidney injury

Sepsis is the commonest precipitating factor for acute kidney injury in hospitalised patients, and similarly patients with acute kidney injury are predisposed to sepsis. Mortality remains high despite improvements in supportive care.

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Above a threshold dialytic dose of 20 ml/kg/h for continuous renal replacement therapy and a sessional Kt/V of 1.2 for intermittent dialysis, further increases in dose do not appear to impact on survival. Similarly, no treatment mode offers survival advantage, and renal support should be targeted to maintain electrolyte homeostasis and correct volume overload. Additional therapies designed to reduce the inflammatory milieu associated with sepsis have been studied, including increased permeability dialysers, plasma filtration and adsorption techniques, endotoxin filters, selective leucapheresis and bio-artificial renal devices. Antibiotic-coated catheters have been shown to reduce catheter-associated bacteraemia.

Although no modality confers survival advantage, prevention of intratreatment hypotension may result in increased dialysis independence in the survivors, and as such treatments should be designed to minimise the risk of hypotension. As patients with acute kidney injury are at risk of sepsis, catheter-associated bacteraemia should be minimised by using antibiotic- or antiseptic-coated catheters, and hub colonisation reduced with appropriate catheter locks. Further trials of adjunct therapies designed to reduce the inflammatory milieu are required before these potential advances can be recommended for clinical practice.