KDIGO Clinical Practice Guideline for Acute Kidney Injury
Protocols for decreasing hemodynamic instability with intermittent RRT

Protocols for decreasing hemodynamic instability with intermittent RRT

Intradialytic hypotension is a major problem during RRT in AKI patients, limiting its efficacy and causing morbidity. Surprisingly, there are only a few studies assessing this highly relevant clinical problem. Paganini et al.⁷³³ performed a small-sample (10 subjects) randomized crossover controlled trial in AKI patients. They evaluated two different RRT protocols: fixed dialysate sodium (140 mEq) and fixed ultrafiltration rate vs. variable dialysate sodium (160 to 140 mEq) and variable ultrafiltration rate (50% in first third of the treatment and 50% in the last two-thirds of the treatment). The variable sodium and ultrafiltration rate protocol achieved better hemodynamic stability, needed fewer interventions, and induced lesser relative blood volume changes, despite higher ultrafiltration rates.

Schortgen et al.⁷³⁴ evaluated the effects of implementing specific guidelines aiming to improve IHD hemodynamic tolerance. The clinical practice algorithm included priming the dialysis circuit with isotonic saline, setting dialysate sodium concentration at 145 mEq/l, discontinuing vasodilator therapy, and setting dialysate temperature to below 37°C. A total of 289 RRT sessions were performed in 76 patients and compared to a historical series of 248 sessions in 45 patients. Hemodynamic tolerance was better in the guideline patients. They developed less systolic drop at and during RRT. They also had less hypotensive episodes and the need for therapeutic interventions was less frequent. The adoption of guidelines did not influence ICU mortality, but death rate was significantly lower than predicted from illness severity in the guideline patients, but not in the historical series subjects. Length of ICU stay was also reduced for survivors in the protocol-oriented group, as compared to the historical series of patients.