Section 5: Dialysis Interventions for Treatment of AKI

Whether or not to provide RRT, and when to start, are two of the fundamental questions facing nephrologists and intensive-care practitioners in most cases of severe AKI. In recent publications, the timing of initiation of RRT was listed as one of the top priorities in research on AKI. However, this dimension has not been included as a factor in any of the large RCTs in this area. The optimal timing of dialysis for AKI is not defined. In current practice, the decision to start RRT is based most often on clinical features of volume overload and biochemical features of solute imbalance (azotemia, hyperkalemia, severe acidosis). However, in the absence of these factors there is generally a tendency to avoid dialysis as long as possible, a thought process that reflects the decisions made for patients with CKD Stage 5. Clinicians tend to delay RRT when they suspect that patients may recover on their own, and because of concern for the well-known risks associated with the RRT procedure, including hypotension, arrhythmia, membrane bioincompatibility, and complications of vascular access and anticoagulant administration. There is also some concern that RRT may compromise recovery of renal function, and increase the progression of CKD. Whether these risks outweigh the potential benefits of earlier initiation of RRT is still unclear.