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A number of organizations have published practice guidelines that include statements on the timing of initiation of RRT in ICU settings (Table 3). In 2012, the Kidney Disease Improving Global Outcomes (KDIGO) group made 2 statements regarding the timing of RRT initiation in AKI, both of which were based on expert opinion and not graded by evidence [4]. The first was a straightforward recommendation to initiate RRT “emergently when life-threatening changes in fluid, electrolyte, and acid-base balance exist.” The second statement asked clinicians to consider the “broader clinical context, the presence of conditions that can be modified with RRT, and trends of laboratory tests – rather than single BUN and creatinine thresholds alone – when making the decision to start RRT. Though the latter statement may be viewed as imprecise by suggesting clinicians use relatively subjective indications in their decision-making, this would appear a reasonable portrayal of current clinical practice. In 2013, the National Institute for Health and Care Excellence in the United Kingdom published statements similar to those proposed by KDIGO [12]. The National Institute for Health and Care Excellence guidelines also highlighted the paucity of high-quality evidence to guide clinician decision-making on this issue. The guidelines further emphasized that clinicians need better tools, such as clinical risk prediction scores or novel point-of-care tests as decision-support that may help identify patients with a higher likelihood of having worsening AKI and those who may benefit from the earlier initiation. In 2015, the French Intensive Care Society also published statements for use of RRT in ICU settings [13]. All of these guideline statements acknowledged the limitations in current evidence with each of them declaring that additional high-quality clinical trials are needed to better inform clinical practice.

Table 3. Summary of clinical practice guidelines for starting RRT in critically ill patients with AKI