Indications and timing of renal replacement therapy

The management of patients with acute kidney injury is mainly supportive in nature, with no available proven therapeutic modalities to treat the condition. Renal replacement therapy (RRT) is indicated in patients with severe kidney injury, or increased volume or metabolic demands. In the absence of clinically significant uremic symptoms or specific indications such as severe electrolyte abnormalities or volume overload, the optimal timing of RRT initiation is controversial. Randomized, controlled trials that have compared strategies of early versus delayed initiation of RRT in the absence of obvious indications have yielded conflicting results. The implementation of decision support systems is challenging but could provide clinicians a framework with specific recommendations for interventions. Recently, some algorithms have been proposed to guide physicians in the decision to initiate, and their application in clinical practice may reduce variations across physicians and centers. The decision on the appropriate time to start RRT is complex, integrating numerous variables, and should largely be individualized, however the lack of definitive parameters to define early or late initiation reveals a great need to continue research on this field. Such evidence is important for reducing variations in the clinical practice of RRT prescription and improving patient outcomes.