Liberation From CRRT (Continuous Renal Replacement Therapy)

Liberation from CKRT
(CRRT)
Dr Ankit Mangla
MD Pediatrics, IDPCCM (ISCCM/IAP), Fellow Pediatric Nephrology
Director and Head Pediatric Nephro Critical care and PICU
HOPE Hospitals, Jaipur, Rajasthan
• Continuous KRT (CKRT) is increasingly preferred in the PICU as a renal
supportive therapy for increased fluid removal tolerability with
associated hemodynamic instability nutrition, AKI with hyponatremia,
dialyzable drugs, poisoning, and intoxicants.
• Its challenging to start CKRT  But its more challenging to wean off
from CKRT
• KDIGO - Acute Kidney Injury Work Group guidelines says : CKRT
should be stopped when “it is no longer required, either
because intrinsic kidney function has recovered to the point that it is

adequate to meet patient needs, or
because RRT is no longer consistent with the goals of care
• Shortcoming : Non specific enough to implement at bedside

• pCKRT liberation should involve a complex multidisciplinary approach
• Pediatric Intensivist
• Pediatric Nephrologist
• Infectious disease specialist
• Dialysis technician
• Nursing staff
• Nutritionist
There can be 2 ways for liberation of CKRT
1. Deescalation to other hybrid modes of KRT
2. Complete cessation of RRT

When to consider Liberation
• No clinical consensus guideline provides specific recommendations
on when and how to stop CKRT in anticipation of renal recovery
• Either premature liberation leading to Early Re-start of KRT

or
• Unnecessary prolonged exposure due to Late liberation
Unnecessary prolonged exposure to CKRT
• complex and expensive therapy
• High resource & manpower demanding
• catheter-associated infections
• Hemorrhage
• hemodynamic instability
• delayed renal recovery
Early Re-start of CKRT
• Re-initiation of CKRT after a failed weaning attempt is associated
with increased LOS and greater mortality
• uncertainty in drug dosing
• Harmful sequelae of AKI, such as fluid accumulation, metabolic

acidosis, and retention of metabolic waste.
Timing of Liberation depends upon
• Indication for start of CKRT
• Naïve Kidney function at the time of de-escalation
• Clinical criteria at the time of de-escalation
• Availability of other hybrid modes of KRT

Indication of starting CKRT
• Those cases with anuria/oligouria and uremia at initialtion of CKRT
has higher need for KRT following CKRT withdrawal
• While cases with sepsis, acidosis or hyperammonemia with

maintained urine output have higher probability of complete renal
recovery
Recovery of native kidney function
• Depends upon
Indication for start of KRT

Severity , type and duration of AKI
Severity of acute disease (multiorgan failure)
Patient demographic factors (age, sex, race)
Pre existing renal diseases (reduced eGFR or pre-admission proteinuria)
Other co-morbidities – post cardiac surgery / organ transplant
Clinical Condition at time of de-escalation
• Sepsis control
• Hemodynamic status
• Fluid overload trajectory
• Urine output in last 6 and 12 hours
• Any other co-morbidity
• CKRT duration before liberation
• Requirement of vasoactive agents within 24 h before liberation
All are independent predictors of CKRT Liberation

Single centre, retrospective study on 1135 adult AKI patients
Availability of Other Hybrid modes
• PIRRT
• IHD
• Peritoneal Dialysis
• Pediatric Nephrology 2023, Wei et al. San Diago
• Urine output > 0.5 mL/kg/hr irrespective of diuretic administration in
the 6-h period before CKRT discontinuation  significant predictor of
successful CKRT weaning
• Those with underlying cardiac disease, post cardiopulmonary bypass,

or had an underlying oncologic disease  higher failure post
liberation
• Other parameters : higher CVP at 6 & 12 hours of CKRT

discontinuation, has higher failure rates
• It included 23 observational studies
• Described 16 variables predicting successful liberation from CRRT
biochemical criteria as surrogates of glomerular filtration rate : serum urea,

serum creatinine, creatinine clearance, urine creatinine excretion
physiologic parameters such as urine output
newer kidney biomarkers : cystatin C and serum neutrophil gelatinase-
associated lipocalin (NGAL).
• Most successful parameter  urine output before stopping CRRT
• Sensitivity and Specificity of 66.2% (95% CI, 53.6–76.9%) and 73.6%
(95% CI, 67.5–79.0%) respectively
In current scenario with lack of consensus statement
• CRRT liberation decisions in clinical practice have been mainly based

on physicians personal experience
• Few predictors have been identified for guiding the weaning from
CKRT
Predictors of Liberation from CRRT
• Increasing Urine Output – 6 hours or 24 hours prior and
– 6 hours or 12 hours post weaning off
• Adequate response to diuretics
• Trial off CKRT with each filter change

Role of Diuretics in CRRT Weaning Trial
• Studies have shown an association of diuretic use with successful
prediction for RRT weaning
• Loop diuretics (furosemide) trial are given
• Represents a functional test
• Requires the integrity of several nephrons from filtration to proximal

tubular secretion and luminal patency
Role of Renal Biomarkers
• Blood Urea
• Serum Creatinine
• Urine creatinine clearance
• Cystatin C, NGAL, IL-18, IL-6

Blood urea and creatinine
• Pre-withdrawal levels during prolonged CRRT breaks can determine the
solute clearance needs
• Lower the levels  Positive predictors for weaning CRRT
• High fluctuations in critically ill patients

Varying muscle mass
Timing of CRRT breaks
Delivered CRRT dose
Diuretics use
Tube feeds
Urine creatinine clearance
• Next best measure of eGFR in ICU
• 24 hour sample is time consuming
• Can be affected by hemodynamic changes

Cystatin C, NGAL, IL-18, IL-6 as biomarkers
• Very limited data
• Only Cystatin C has been studied and
• found to be an independent positive predictor for weaning off CRRT
• Limitations : corticosteroid use, thyroid dysfunction, and underlying

malignancy.
• Lot of work needed to establish its clinical use

Transition off CRRT
• Hybrid therapies –
PIRRT
SLEDD
Extended daily dialysis
• Intermittent HD (IHD)
CRRT weaning/transition in
specific disease situations
CRRT in AKI with Hyponatremia
• Role of CRRT is increasing d/t ability to control the rate of sodium
increase with customization of dialysate
• Can be transitioned to Intermittent HD once sodium levels reach 125-

130mEq/L
CRRT in Hyperammonemia
• Can be used as bridge to transplant or till native liver function
improved
• Can be weaned off once mental status, ammonia levels, and

hemodynamics improve
• Usually no role of urine output / creatinine as predictor for CRRT de-

escalation
CRRT in Poisioning
• greater clearance of large molecules
• prevents the rebound of toxins removed from intravascular space
• Hemoperfusion filters are available for specific poisioning
• Liberation can be done once the goal of poison removal is achieved

• Two ongoing pilot randomized trials in adult patients—
1. Promoting Kidney Recovery After Acute Kidney Injury Receiving

Dialysis (Recover-AKI) &
2. Liberation from Acute Dialysis (LIBERATE-D): will end by Dec 24
Though both studies are done on KRT modalities and not specific for
CKRT
THANK YOU

Liberation From CRRT (Continuous Renal Replacement Therapy)

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Liberation from CKRT

because intrinsic kidney function has recovered to the point that it is

because RRT is no longer consistent with the goals of care

• Shortcoming : Non specific enough to implement at bedside

1. Deescalation to other hybrid modes of KRT

2. Complete cessation of RRT

• Either premature liberation leading to Early Re-start of KRT

• uncertainty in drug dosing

• Harmful sequelae of AKI, such as fluid accumulation, metabolic

• Naïve Kidney function at the time of de-escalation

• Clinical criteria at the time of de-escalation

• Availability of other hybrid modes of KRT

• While cases with sepsis, acidosis or hyperammonemia with

Indication for start of KRT

All are independent predictors of CKRT Liberation

• Those with underlying cardiac disease, post cardiopulmonary bypass,

• Other parameters : higher CVP at 6 & 12 hours of CKRT

biochemical criteria as surrogates of glomerular filtration rate : serum urea,

• CRRT liberation decisions in clinical practice have been mainly based

• Adequate response to diuretics

• Trial off CKRT with each filter change

• Loop diuretics (furosemide) trial are given

• Represents a functional test

• Requires the integrity of several nephrons from filtration to proximal

• Urine creatinine clearance

• Cystatin C, NGAL, IL-18, IL-6

• Lower the levels  Positive predictors for weaning CRRT

• High fluctuations in critically ill patients

• 24 hour sample is time consuming

• Can be affected by hemodynamic changes

• Only Cystatin C has been studied and

• found to be an independent positive predictor for weaning off CRRT

• Limitations : corticosteroid use, thyroid dysfunction, and underlying

• Lot of work needed to establish its clinical use

• Can be transitioned to Intermittent HD once sodium levels reach 125-

• Can be weaned off once mental status, ammonia levels, and

• Usually no role of urine output / creatinine as predictor for CRRT de-

• prevents the rebound of toxins removed from intravascular space

• Hemoperfusion filters are available for specific poisioning

• Liberation can be done once the goal of poison removal is achieved

1. Promoting Kidney Recovery After Acute Kidney Injury Receiving

2. Liberation from Acute Dialysis (LIBERATE-D): will end by Dec 24

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