Stopping Dialysis After Acute Kidney Injury, But When?
Acute kidney injury (AKI) is a sudden episode of kidney failure or kidney damage that happens within a few hours or a few days due to a sudden drop in blood pressure, complication from surgery, or adverse medication reaction. AKI causes a build-up of waste products in the blood and makes it hard for the kidneys to keep the right balance of fluid in the body. AKI can also affect other organs such as the brain, heart, and lungs. Acute kidney injury is common in patients who are in the hospital, in intensive care units, and especially in older adults.
A patient suffering from an acute kidney injury (AKI) is usually treated with some form of renal replacement therapy (RRT), more commonly referred to as dialysis. RRTs are various ways of filtrating the blood, either with or without machines, including hemodialysis, peritoneal dialysis, hemofiltration, or hemodiafiltration. Mallika Mendu, MD, MBA, Associate Medical Director for Specialty Care at Partners Population Health, along with other researchers from Brigham and Women’s Hospital, noticed there was wide variation in when clinicians decided to discontinue renal replacement therapy (RRT) after an acute kidney injury.
“The problem is, prolonged, unnecessary RRT can contribute to a longer length of stay in the hospital, increase overall hospital costs, and can lead to complications associated with RRT,” says Dr. Mendu. “The timing of when a clinician decides to discontinue RRT treatment in acute kidney injury patients can significantly impact clinical outcomes.”
In their recent Editorial, “When to stop renal replacement therapy in anticipation of renal recovery in AKI: The need for consensus guidelines,” from Seminars In Dialysis, Drs. Mendu, Kelly, and Waikar explore randomized clinical trials that used varied discontinuation criteria.
In their article, Dr. Mendu and her co-collaborators propose a starting framework for RRT discontinuation criteria to guide clinicians and clinical researchers. In their review, they focused on guidelines related to urine output and creatinine clearance. Their guidelines for suspension of RRT treatment? STOP.
STOP: Criteria for Consideration of RRT Cessation
- Need for volume removal does not exceed daily urine output
- No hyperkalemia refracting to medical management
- No acidemia refractory to medical management
TIMED Urine Creatinine Clearance
- >15 ml/min on 24-hour collection
- Urine output >400ml/24-hours
- Urine output >2000ml/24-hours with diuretics
While the Brigham team outlines the STOP criteria as a starting point, they emphasize the importance of frequent clinical assessment while considering discontinuation of RRT for AKI patients.
Their paper also explores new, novel methods for tracking AKI patient outcomes. They cite emerging evidence to screen for biomarkers other than creatinine, like serum cystatin C, and how they may play a role in assessing renal recovery after an Acute Kidney Injury. They also look at novel methods of the glomerular filtration rate (GFR)—a test used to check how well the kidneys are working—as well as new imaging techniques like MRI‐chemical exchange saturation transfer (CEST) pH imaging and Arterial spin labeling perfusion MRI. Although there is not yet hard evidence that these methods will supersede the current clinical guidelines, these nascent technologies show promise for future clinical applications in RRT discontinuation management.
“In nephrology and in other fields of medicine, overtreatment can contribute to preventable harm and increased healthcare cost,” says Dr. Mendu. “The STOP framework, which guides clinicians about when to stop RRT treatments (dialysis), starts the conversation about the importance of avoiding overutilization of care.”
*Employees of the Partners HealthCare system can access this article through the MGH Treadwell Library.
Kelly, Y. P., Waikar, S. S., & Mendu, M. L. (2019). When to stop renal replacement therapy in anticipation of renal recovery in AKI: The need for consensus guidelines. Seminars In Dialysis.