Is there an ideal dose of dialysis

Is there an ideal dose of dialysis?

Since 2000, multiple studies in IHD as well as in CRRT have suggested that higher doses of RRT are associated with improved outcomes; however, two large multicenter, randomized, control trials (ATN study and RENAL study) do not support the hypothesis that a higher dose of RRT will improve outcomes.

It appears that the relationship between the dose administered by RRT and survival has two regions: a dosage-dependent region where increases in the intensity of the dose are associated with improved survival; and a dosage-independent region after a threshold is reached.

A further increase in the intensity of dose does not improve outcomes.

These two studies suggest that dose should be measured, rather than implying that dose is not important in the treatment of critically ill patients with AKI. The influence on solute clearance of some operational characteristics of RRT, such as frequent filter clotting and protein fouling of the membrane, can translate into a lower dose of delivered dialysis; this explains why a simple prescription of a target dose, or adjusting for treatment interruptions, is not enough to find an ideal dose of dialysis.

In order to ensure delivery of an effluent flow rate of 20 to 25 mL/kg per hour as recommended by 2012 KDIGO guidelines, we recommend prescribing an effluent flow rate of >25 mL/kg per hour in order to achieve the targeted dose of therapy. For patients undergoing IHD, KDIGO recommend delivering a Kt/V of 3.9 per week.

This recommendation is based on the results of the ATN study, and is just the arithmetic sum of the median dose in the less intensive arm that has been summed over the course of a week.

It is recommended that if IHD is provided three times per week, the targeted dose of therapy should be a Kt/V of ≥1.2 per treatment. The delivered dose of therapy should be monitored.

Besides a small solute clearance, other aspects of dosing should be considered (volume control, acid-base, nutritional status, etc.) in order to find an ideal dose of dialysis during Acute Kidney Injury.

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