UMEM Educational Pearls

Title: When To Initiate RRT in the Critically Ill

Posted: 7/1/2025 by Mike Winters, MBA, MD (Updated: 7/18/2025)
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When To Initiate RRT in the Critically Ill Patient

Acute kidney injury (AKI) occurs in more than half of critically ill patients admitted to the ICU.
When and how to initiate renal replacement therapy (RRT) in the critically ill patient remains debated.
While a strategy of deferred RRT is preferable in many, indications for immediate RRT in patients with AKI include the following:
- Potassium > 6.5 that is refractory to medical therapy
- pH < 7.15 that is not responsive to bicarbonate administration
- Fluid overload (worsening pulmonary edema, P/F ratio < 200 mm Hg) that is refractory to diuretics

Barbar SD, Wald R, Quenot JP. Acute kidney injury: when and how to start renal replacement therapy. Intensive Care Med. 2025;51:1172-1175.