Blood purification: from renal replacement to organ support_West China Medical Journal

Authors：

 YANG Rongli

Department of Critical Care Medicine, Central Hospital of Dalian University of Technology, Dalian, Liaoning 116033, P. R. China;

Corresponding author：

YANG Rongli, Email: yever3000@dlut.edu.cn

Keywords：

Blood purification; renal replacement; renal support; extracorporeal multiple organ support

DOI：

10.7507/1002-0179.202307044

Video：

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Patients with severe acute kidney injury (AKI) often need renal replacement therapy (RRT）with a high morbidity and mortality. For patients with chronic renal failure, the aim of blood purification is renal replacement; but for patients with AKI, although customarily called RRT, the aim of blood purification is not “renal replacement”, but extracorporeal “renal support and protection”, that is, supporting and protecting temporally failed kidney, removing damage factors, avoiding renal reinjury and looking forward to restore renal function. This article provides a detailed explanation of the differences between renal replacement and renal support from the perspective of organ protection, as well as the key links of RRT and extracorporeal multiple organ support for patients with severe AKI.

Citation： YANG Rongli. Blood purification: from renal replacement to organ support. West China Medical Journal, 2023, 38(7): 969-973. doi: 10.7507/1002-0179.202307044 Copy

1.	Quenot JP, Amrouche I, Lefrant JY, et al. Renal replacement therapy for acute kidney injury in French intensive care units: a nationwide survey of practices. Blood Purif, 2022, 51(8): 698-707.
2.	Hoste EAJ, Kellum JA, Selby NM, et al. Global epidemiology and outcomes of acute kidney injury. Nat Rev Nephrol, 2018, 14(10): 607-625.
3.	Digvijay K, Neri M, Fan W, et al. International survey on the management of acute kidney injury and continuous renal replacement therapies: year 2018. Blood Purif, 2019, 47(1/2/3): 113-119.
4.	杨荣利, 李素玮, 陈秀凯, 等. 重症血液净化: 从技术到科学. 中华医学杂志, 2017, 97(29): 2241-2243.
5.	Mehta RL. Indications for dialysis in the ICU: renal replacement vs. renal support. Blood Purif, 2001, 19(2): 227-232.
6.	Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract, 2012, 120(4): c179-c184.
7.	Forni LG, Darmon M, Schetz M. Renal replacement in 2050: from renal support to renal replacement?. Intensive Care Med, 2017, 43(7): 1044-1047.
8.	Ostermann M, Joannidis M, Pani A, et al. Patient selection and timing of continuous renal replacement therapy. Blood Purif, 2016, 42(3): 224-237.
9.	Tiwari SC, Bhowmik DM, Dash SC. Is the term ‘renal support therapy’ more appropriate than ‘renal replacement therapy’?. Nephrol Dial Transplant, 2005, 20(8): 1770-1771.
10.	Chawla LS, Kellum JA, Ronco C. Permissive hypofiltration. Crit Care, 2012, 16(4): 317.
11.	Clark EG, Bagshaw SM. Unnecessary renal replacement therapy for acute kidney injury is harmful for renal recovery. Semin Dial, 2015, 28(1): 6-11.
12.	Lan SH, Lai CC, Chang SP, et al. Accelerated-strategy renal replacement therapy for critically ill patients: a systematic review and meta-analysis. Medicine (Baltimore), 2022, 101(27): e29747.
13.	Gaudry S, Hajage D, Schortgen F, et al. Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med, 2016, 375(2): 122-133.
14.	STARRT-AKI Investigators, Canadian Critical Care Trials Group, Australian and New Zealand Intensive Care Society Clinical Trials Group, et al. Timing of initiation of renal-replacement therapy in acute kidney injury. N Engl J Med, 2020, 383(3): 240-251.
15.	Barbar SD, Clere-Jehl R, Bourredjem A, et al. Timing of renal-replacement therapy in patients with acute kidney injury and sepsis. N Engl J Med, 2018, 379(15): 1431-1442.
16.	Naorungroj T, Neto AS, Wang A, et al. Renal outcomes according to renal replacement therapy modality and treatment protocol in the ATN and RENAL trials. Crit Care, 2022, 26(1): 269.
17.	Bonnassieux M, Duclos A, Schneider AG, et al. Renal replacement therapy modality in the ICU and renal recovery at hospital discharge. Crit Care Med, 2018, 46(2): e102-e110.
18.	Wald R, Shariff SZ, Adhikari NK, et al. The association between renal replacement therapy modality and long-term outcomes among critically ill adults with acute kidney injury: a retrospective cohort study. Crit Care Med, 2014, 42(4): 868-877.
19.	Dalbhi SA, Alorf R, Alotaibi M, et al. Sustained low efficiency dialysis is non-inferior to continuous renal replacement therapy in critically ill patients with acute kidney injury: a comparative meta-analysis. Medicine (Baltimore), 2021, 100(51): e28118.
20.	Harvey AK, Burns KEA, McArthur E, et al. Short-and long-term outcomes of sustained low efficiency dialysis vs continuous renal replacement therapy in critically ill patients with acute kidney injury. J Crit Care, 2021, 62: 76-81.
21.	Honore PM, Blackman S, Perriens E, et al. Is prolonged intermittent renal replacement therapy actually safe for hemodynamically unstable patients. Crit Care, 2023, 27(1): 159.
22.	Hoff BM, Maker JH, Dager WE, et al. Antibiotic dosing for critically ill adult patients receiving intermittent hemodialysis, prolonged intermittent renal replacement therapy, and continuous renal replacement therapy: an update. Ann Pharmacother, 2020, 54(1): 43-55.
23.	Shirazian A, Peralta-Cuervo AF, Aguilera-Pena MP, et al. Sustained low-efficiency dialysis is associated with worsening cerebral edema and outcomes in intracerebral hemorrhage. Neurocrit Care, 2021, 35(1): 221-231.
24.	Khan SF. Peritoneal dialysis as a renal replacement therapy modality for patients with acute kidney injury. J Clin Med, 2022, 11(12): 3270.
25.	Al-Hwiesh A, Abdul-Rahman I, Finkelstein F, et al. Acute kidney injury in critically ill patients: a prospective randomized study of tidal peritoneal dialysis versus continuous renal replacement therapy. Ther Apher Dial, 2018, 22(4): 371-379.
26.	Akhoundi A, Singh B, Vela M, et al. Incidence of adverse events during continuous renal replacement therapy. Blood Purif, 2015, 39(4): 333-339.
27.	Bray BD, Boyd J, Daly C, et al. How safe is renal replacement therapy? A national study of mortality and adverse events contributing to the death of renal replacement therapy recipients. Nephrol Dial Transplant, 2014, 29(3): 681-687.
28.	Bagshaw SM, Chakravarthi MR, Ricci Z, et al. Precision continuous renal replacement therapy and solute control. Blood Purif, 2016, 42(3): 238-247.
29.	Murugan R, Hoste E, Mehta RL, et al. Precision fluid management in continuous renal replacement therapy. Blood Purif, 2016, 42(3): 266-278.
30.	Cerdá J, Baldwin I, Honore PM, et al. Role of technology for the management of AKI in critically ill patients: from adoptive technology to precision continuous renal replacement therapy. Blood Purif, 2016, 42(3): 248-265.
31.	杨荣利, 陈秀凯. 连续血液净化与精准容量管理. 中华医学杂志, 2018, 98(35): 2792-2795.
32.	丛刘霞, 杨荣利, 刘思伯. 连续血液净化治疗的容量评估进展. 中华医学杂志, 2020, 100(23): 1837-1840.
33.	Neyra JA, Kashani K. Improving the quality of care for patients requiring continuous renal replacement therapy. Semin Dial, 2021, 34(6): 501-509.
34.	Ruiz EF, Ortiz-Soriano VM, Talbott M, et al. Development, implementation and outcomes of a quality assurance system for the provision of continuous renal replacement therapy in the intensive care unit. Sci Rep, 2020, 10(1): 20616.
35.	Ronco C, Bellomo R. Acute renal failure and multiple organ dysfunction in the ICU: from renal replacement therapy (RRT) to multiple organ support therapy (MOST). Int J Artif Organs, 2002, 25(8): 733-747.
36.	Ronco C, Ricci Z, Husain-Syed F. From multiple organ support therapy to extracorporeal organ support in critically ill patients. Blood Purif, 2019, 48(2): 99-105.
37.	Vincent JL. Introduction to extracorporeal multiple organ support. Blood Purif, 2019, 48(2): 97-98.
38.	Acharya M, Berger R, Popov AF. The role of the ADVanced Organ Support (ADVOS) system in critically ill patients with multiple organ failure. Artif Organs, 2022, 46(5): 735-746.
39.	Huber W, Ruiz de Garibay AP. Options in extracorporeal support of multiple organ failure. Med Klin Intensivmed Notfmed, 2020, 115(Suppl 1): 28-36.
40.	Martins Costa A, Halfwerk F, Wiegmann B, et al. Trends, advantages and disadvantages in combined extracorporeal lung and kidney support from a technical point of view. Front Med Technol, 2022, 4: 909990.
41.	Wiegmann B, Maurer A, Zhang R, et al. Combined pulmonary and renal support in a single extracorporeal device. ASAIO J, 2013, 59(4): 433-438.
42.	Chevtchik NV, Mihajlovic M, Fedecostante M, et al. A bioartificial kidney device with polarized secretion of immune modulators. J Tissue Eng Regen Med, 2018, 12(7): 1670-1678.
43.	Wang Y, Zheng Q, Sun Z, et al. Reversal of liver failure using a bioartificial liver device implanted with clinical-grade human-induced hepatocytes. Cell Stem Cell, 2023, 30(5): 617-631.e8.

1. Quenot JP, Amrouche I, Lefrant JY, et al. Renal replacement therapy for acute kidney injury in French intensive care units: a nationwide survey of practices. Blood Purif, 2022, 51(8): 698-707.
2. Hoste EAJ, Kellum JA, Selby NM, et al. Global epidemiology and outcomes of acute kidney injury. Nat Rev Nephrol, 2018, 14(10): 607-625.
3. Digvijay K, Neri M, Fan W, et al. International survey on the management of acute kidney injury and continuous renal replacement therapies: year 2018. Blood Purif, 2019, 47(1/2/3): 113-119.
4. 杨荣利, 李素玮, 陈秀凯, 等. 重症血液净化: 从技术到科学. 中华医学杂志, 2017, 97(29): 2241-2243.
5. Mehta RL. Indications for dialysis in the ICU: renal replacement vs. renal support. Blood Purif, 2001, 19(2): 227-232.
6. Khwaja A. KDIGO clinical practice guidelines for acute kidney injury. Nephron Clin Pract, 2012, 120(4): c179-c184.
7. Forni LG, Darmon M, Schetz M. Renal replacement in 2050: from renal support to renal replacement?. Intensive Care Med, 2017, 43(7): 1044-1047.
8. Ostermann M, Joannidis M, Pani A, et al. Patient selection and timing of continuous renal replacement therapy. Blood Purif, 2016, 42(3): 224-237.
9. Tiwari SC, Bhowmik DM, Dash SC. Is the term ‘renal support therapy’ more appropriate than ‘renal replacement therapy’?. Nephrol Dial Transplant, 2005, 20(8): 1770-1771.
10. Chawla LS, Kellum JA, Ronco C. Permissive hypofiltration. Crit Care, 2012, 16(4): 317.
11. Clark EG, Bagshaw SM. Unnecessary renal replacement therapy for acute kidney injury is harmful for renal recovery. Semin Dial, 2015, 28(1): 6-11.
12. Lan SH, Lai CC, Chang SP, et al. Accelerated-strategy renal replacement therapy for critically ill patients: a systematic review and meta-analysis. Medicine (Baltimore), 2022, 101(27): e29747.
13. Gaudry S, Hajage D, Schortgen F, et al. Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med, 2016, 375(2): 122-133.
14. STARRT-AKI Investigators, Canadian Critical Care Trials Group, Australian and New Zealand Intensive Care Society Clinical Trials Group, et al. Timing of initiation of renal-replacement therapy in acute kidney injury. N Engl J Med, 2020, 383(3): 240-251.
15. Barbar SD, Clere-Jehl R, Bourredjem A, et al. Timing of renal-replacement therapy in patients with acute kidney injury and sepsis. N Engl J Med, 2018, 379(15): 1431-1442.
16. Naorungroj T, Neto AS, Wang A, et al. Renal outcomes according to renal replacement therapy modality and treatment protocol in the ATN and RENAL trials. Crit Care, 2022, 26(1): 269.
17. Bonnassieux M, Duclos A, Schneider AG, et al. Renal replacement therapy modality in the ICU and renal recovery at hospital discharge. Crit Care Med, 2018, 46(2): e102-e110.
18. Wald R, Shariff SZ, Adhikari NK, et al. The association between renal replacement therapy modality and long-term outcomes among critically ill adults with acute kidney injury: a retrospective cohort study. Crit Care Med, 2014, 42(4): 868-877.
19. Dalbhi SA, Alorf R, Alotaibi M, et al. Sustained low efficiency dialysis is non-inferior to continuous renal replacement therapy in critically ill patients with acute kidney injury: a comparative meta-analysis. Medicine (Baltimore), 2021, 100(51): e28118.
20. Harvey AK, Burns KEA, McArthur E, et al. Short-and long-term outcomes of sustained low efficiency dialysis vs continuous renal replacement therapy in critically ill patients with acute kidney injury. J Crit Care, 2021, 62: 76-81.
21. Honore PM, Blackman S, Perriens E, et al. Is prolonged intermittent renal replacement therapy actually safe for hemodynamically unstable patients. Crit Care, 2023, 27(1): 159.
22. Hoff BM, Maker JH, Dager WE, et al. Antibiotic dosing for critically ill adult patients receiving intermittent hemodialysis, prolonged intermittent renal replacement therapy, and continuous renal replacement therapy: an update. Ann Pharmacother, 2020, 54(1): 43-55.
23. Shirazian A, Peralta-Cuervo AF, Aguilera-Pena MP, et al. Sustained low-efficiency dialysis is associated with worsening cerebral edema and outcomes in intracerebral hemorrhage. Neurocrit Care, 2021, 35(1): 221-231.
24. Khan SF. Peritoneal dialysis as a renal replacement therapy modality for patients with acute kidney injury. J Clin Med, 2022, 11(12): 3270.
25. Al-Hwiesh A, Abdul-Rahman I, Finkelstein F, et al. Acute kidney injury in critically ill patients: a prospective randomized study of tidal peritoneal dialysis versus continuous renal replacement therapy. Ther Apher Dial, 2018, 22(4): 371-379.
26. Akhoundi A, Singh B, Vela M, et al. Incidence of adverse events during continuous renal replacement therapy. Blood Purif, 2015, 39(4): 333-339.
27. Bray BD, Boyd J, Daly C, et al. How safe is renal replacement therapy? A national study of mortality and adverse events contributing to the death of renal replacement therapy recipients. Nephrol Dial Transplant, 2014, 29(3): 681-687.
28. Bagshaw SM, Chakravarthi MR, Ricci Z, et al. Precision continuous renal replacement therapy and solute control. Blood Purif, 2016, 42(3): 238-247.
29. Murugan R, Hoste E, Mehta RL, et al. Precision fluid management in continuous renal replacement therapy. Blood Purif, 2016, 42(3): 266-278.
30. Cerdá J, Baldwin I, Honore PM, et al. Role of technology for the management of AKI in critically ill patients: from adoptive technology to precision continuous renal replacement therapy. Blood Purif, 2016, 42(3): 248-265.
31. 杨荣利, 陈秀凯. 连续血液净化与精准容量管理. 中华医学杂志, 2018, 98(35): 2792-2795.
32. 丛刘霞, 杨荣利, 刘思伯. 连续血液净化治疗的容量评估进展. 中华医学杂志, 2020, 100(23): 1837-1840.
33. Neyra JA, Kashani K. Improving the quality of care for patients requiring continuous renal replacement therapy. Semin Dial, 2021, 34(6): 501-509.
34. Ruiz EF, Ortiz-Soriano VM, Talbott M, et al. Development, implementation and outcomes of a quality assurance system for the provision of continuous renal replacement therapy in the intensive care unit. Sci Rep, 2020, 10(1): 20616.
35. Ronco C, Bellomo R. Acute renal failure and multiple organ dysfunction in the ICU: from renal replacement therapy (RRT) to multiple organ support therapy (MOST). Int J Artif Organs, 2002, 25(8): 733-747.
36. Ronco C, Ricci Z, Husain-Syed F. From multiple organ support therapy to extracorporeal organ support in critically ill patients. Blood Purif, 2019, 48(2): 99-105.
37. Vincent JL. Introduction to extracorporeal multiple organ support. Blood Purif, 2019, 48(2): 97-98.
38. Acharya M, Berger R, Popov AF. The role of the ADVanced Organ Support (ADVOS) system in critically ill patients with multiple organ failure. Artif Organs, 2022, 46(5): 735-746.
39. Huber W, Ruiz de Garibay AP. Options in extracorporeal support of multiple organ failure. Med Klin Intensivmed Notfmed, 2020, 115(Suppl 1): 28-36.
40. Martins Costa A, Halfwerk F, Wiegmann B, et al. Trends, advantages and disadvantages in combined extracorporeal lung and kidney support from a technical point of view. Front Med Technol, 2022, 4: 909990.
41. Wiegmann B, Maurer A, Zhang R, et al. Combined pulmonary and renal support in a single extracorporeal device. ASAIO J, 2013, 59(4): 433-438.
42. Chevtchik NV, Mihajlovic M, Fedecostante M, et al. A bioartificial kidney device with polarized secretion of immune modulators. J Tissue Eng Regen Med, 2018, 12(7): 1670-1678.
43. Wang Y, Zheng Q, Sun Z, et al. Reversal of liver failure using a bioartificial liver device implanted with clinical-grade human-induced hepatocytes. Cell Stem Cell, 2023, 30(5): 617-631.e8.

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