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Continuous renal replacement therapy, sustained low-efficiency dialysis, and intermittent hemodialysis for acute kidney injury — KDIGO evidence, hemodynamic considerations, and ICU integration.
Evidence reviewed & updated: 2026-07 — reflects the latest published trials and guidelines.
For acute kidney injury, KDIGO 2012 concludes: use continuous and intermittent modalities as complementary — CRRT for hemodynamically unstable patients, SLED as a hybrid (extended, gentler, cheaper), and IHD for stable patients. No modality shows survival superiority when adequately delivered; the key is avoiding treatment dose inadequacy and hemodynamic instability during dialysis.
KDIGO AKI Guideline 2012 reviewed 16+ randomized trials comparing CRRT and IHD. The conclusion: 'Use CRRT and IHD as complementary therapies... no difference in patient outcomes between modalities' when dose targets are met. The classic ATN study (NEJM 2008) and RENAL study (NEJM 2009) established dose targets and confirmed no survival difference between higher-intensity strategies.
The largest head-to-head randomized data found no 28-day or 90-day mortality difference between CRRT and IHD. The practical driver of outcomes is: timely initiation, adequate delivered dose, and avoidance of intradialytic hypotension.
Recent analyses suggest CRRT may benefit patients with severe sepsis and those needing aggressive fluid removal, while IHD is cost-efficient for stable patients. The modern approach: a 'kidney replacement therapy bundle' with flexible modality selection per patient.
Modalities: CVVH (convective), CVVHD (diffusive), CVVHDF (both). Runs 24 hours, delivered dose target 20-25 mL/kg/hr (effluent). Preferred for: hemodynamic instability, fluid overload (net UF controllable to mL precision), cerebral edema (no rapid osmotic shifts), and severe AKI in ICU.
Anticoagulation: regional citrate preferred (KRT bleeding risk lowest) — requires protocolized monitoring of ionized calcium and citrate accumulation. Heparin is an alternative in low bleeding risk.
Nursing burden: significant — hourly documentation, filter changes every 24-72 hours, and fluid balance reconciliation. ZuvFlo's CRRT module automates effluent dose tracking, filter pressure monitoring, and fluid balance — reducing documentation time ~30%.
SLED (also SLEDD, EDD) delivers conventional HD machines over extended 8-12 hour sessions at lower blood flow (Qb 150-200 mL/min) and dialysate flow (Qd 200-300 mL/min). It combines: (a) hemodynamic tolerance approaching CRRT, (b) standard HD machine availability (no dedicated CRRT equipment), (c) significantly lower cost.
Evidence: comparative studies show SLED achieves comparable solute control and hemodynamic stability to CRRT at 40-60% lower cost. No randomized survival difference. Ideal for centers without CRRT machines but with ICU patients needing gentle dialysis.
Practical notes: SLED occupies an HD machine for 8-12 hours (schedule off-peak), requires ICU-capable nursing, and anticoagulation follows conventional HD protocols (heparin or no-anticoagulation with saline flushes).
ICU admission with AKI: start with the modality your unit can deliver safely. If only IHD is available, deliver it carefully — reduce Qb/Qd, extend to 4 hours, and monitor BP aggressively. If CRRT/SLED available, use hemodynamic status to select: MAP <65 mmHg on vasopressors → CRRT or SLED; stable → IHD or SLED.
The decision should also consider: cerebral edema (CRRT preferred), severe hyperkalemia (IHD clears fastest), fluid removal needs (CRRT most precise), bleeding risk (citrate CRRT), and resource availability.
Document modality selection rationale — NABH-quality documentation and registry-grade data require structured modality records. ZuvFlo's acute dialysis module supports all three modalities with structured prescriptions and outcome tracking.
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This content is a general reference, not medical advice, a diagnosis, or a treatment plan. Do not change your diet, fluids, medicines, or dialysis plan without your nephrologist or renal dietitian. Individual recommendations depend on your labs, medications, conditions, and care plan.