Multidisciplinary care
Care of the patient receiving continuous kidney replacement therapy (CKRT)
Team coordination
CKRT care requires coordination between intensive-care medicine, nephrology, nursing, pharmacy, nutrition and physiotherapy. Daily review includes the treatment prescription, access function, delivered dose, fluids, electrolytes, medications, nutrition and mobilisation, according to the patient’s condition [2,3].
Drug dosing
Drug removal during CKRT is influenced by the drug’s properties, treatment dose and flow rate, protein binding, volume of distribution, membrane characteristics, residual kidney function and treatment interruptions. There is therefore no single rule suitable for increasing or decreasing all drug doses [2].
In general, despite variation between patients, CKRT usually provides a total daily clearance dose lower than the clearance provided by normal kidney function, but substantially higher than that provided by intermittent haemodialysis (IHD). Required doses of dialysable drugs in patients receiving CKRT are therefore usually higher than doses recommended for IHD patients, but lower than those used in patients with normal kidney function.
Nevertheless, the drug level actually achieved in an individual patient depends on multiple factors, including:
— CKRT dose.
— Residual kidney function.
— The extent of drug adsorption onto the haemofilter.
— Changes in the volume of distribution.
— And changes in protein binding.
Changes in volume of distribution and protein binding are common in critically ill patients.
Predicting drug levels in these patients is therefore difficult, and patients receiving CKRT are susceptible to both excessive and inadequate drug dosing.
This may cause important harm, particularly when treating septic patients with dialysable antimicrobial agents. Coordination with critical-care pharmacists experienced in CKRT is therefore essential, and therapeutic drug monitoring (TDM) is recommended whenever feasible.
Nutrition and Physical Rehabilitation
CKRT may contribute substantially to the negative nitrogen balance commonly observed in critically ill patients as a result of inflammatory injury and catabolic metabolic states.
In healthy kidneys, amino acids and small peptides are filtered by the glomeruli but are almost completely reabsorbed in the proximal tubules. During CKRT, however, non-selective loss of approximately 10–20 grams of amino acids per day may occur, together with loss of other water-soluble micronutrients.
Although more data are needed, it is biologically plausible that amino-acid loss caused by CKRT may contribute to worsening ICU-acquired weakness.
To compensate for these losses, ESPEN guidelines recommend a protein target of 1.5 g/kg/day for critically ill patients with AKI or AKI on CKD receiving CKRT or PIKRT, which may be increased to 1.7 g/kg/day according to the published recommendation. The plan is individualised according to nutritional and metabolic status and patient tolerance, in coordination with a dietitian [1].
Nutrient losses through CKRT are reviewed when estimating requirements; loss of a particular compound is not directly converted into a fixed nutritional dose without clinical assessment [1,2].
Rehabilitation and mobilisation
The team assesses the suitability of early mobilisation according to the patient’s stability, the security of the catheter and tubing, device settings and the team’s ability to secure the circuit. Mobilisation is performed under specialist supervision and in accordance with the local critical-care protocol [2].
Performance and quality monitoring
Monitoring CKRT Performance
Because mortality in critically ill patients with AKI requiring CKRT is approximately 50%, these patients face a high risk of adverse outcomes.
To ensure patients receive the highest possible quality of care, quality-assurance programmes should be incorporated into CKRT programmes. The development and implementation of quality measures specific to CKRT care has only begun in recent years.
Structured review helps document what was prescribed and what the patient actually received. A local monitoring dashboard may include operational indicators such as treatment-interruption duration, filter life, delivered versus prescribed dose, and achieved versus target UFnet. Operational indicators alone are not interpreted as improved patient outcomes [2,3].
Indicator | What is reviewed |
|---|---|
Dose | Prescribed versus actually delivered |
Fluids | Prescribed versus achieved UFnet and the patient’s overall fluid balance |
Circuit | Interruption duration and causes, and filter life |
Safety | Laboratory tests, clinical response and adverse events |
Quality measures and performance indicators
A systematic review published in 2017 identified a number of potential quality measures reported in the scientific literature.
However, studies varied substantially in how these measures were reported, assessed and defined.
The same group subsequently defined, ranked and prioritised the proposed quality measures and converted them into key performance indicators (KPIs) for CKRT care. These indicators were organised within a framework comprising:
— Structure measures.
— Process measures.
— Outcome measures.
Quality-assurance programmes in CKRT
Several examples of successful CKRT quality-assurance programmes have been published. Mottes and colleagues created a CKRT dashboard to monitor process and outcome indicators within a paediatric CKRT programme.
The monitored indicators included:
— Filter life.
— Actually delivered versus prescribed dose.
— Actually delivered versus prescribed net ultrafiltration.
— Survival.
The researchers showed that monitoring these indicators can improve efficiency and performance.
Improving performance using quality indicators
Within an adult CKRT programme, Ruiz and colleagues showed that performance improvements could be achieved through:
— Monitoring similar key performance indicators.
— Providing targeted education based on audits and feedback.
— Focusing particularly on the performance indicators with the poorest results.
This strategy improved filter life, the frequency of device alarms and costs, while maintaining similar clinical outcomes in patients.
Implementing quality programmes in CKRT
Further research is ongoing to determine:
— Which key performance indicators have the greatest effect on outcomes important to patients.
— Which have the greatest effect on healthcare-system outcomes.
— And the best ways to implement CKRT quality programmes effectively.
At present, the following local factors should be considered when establishing a CKRT quality-assurance programme:
— Local patient demographics.
— Local clinical-practice patterns.
— Local information-technology infrastructure.
— Locally available expertise.
— Baseline key-performance-indicator data before the improvement programme begins.
Process
References
[1] Sabatino A, et al. ESPEN practical guideline on clinical nutrition in hospitalized patients with acute or chronic kidney disease. Clin Nutr. 2024;43:2238–2254. doi:10.1016/j.clnu.2024.08.002.
[2] Tandukar S, Palevsky PM. Continuous Renal Replacement Therapy: Who, When, Why, and How. Chest. 2019;155:626–638. doi:10.1016/j.chest.2018.09.004.
[3] KDIGO. Clinical Practice Guideline for Acute Kidney Injury. Kidney Int Suppl. 2012;2:1–138.