From the Guidelines
Early hemodialysis (HD) in acute kidney injury (AKI) due to acute heart failure should be initiated based on the patient's overall clinical status, including volume overload, severe metabolic acidosis, hyperkalemia, or uremic symptoms, rather than solely on creatinine levels. The decision to start HD should be tailored to the individual patient's needs, taking into account their response to medical management and the presence of life-threatening complications. According to the 2020 Kidney Disease: Improving Global Outcomes (KDIGO) conference 1, the provision of renal replacement therapy (RRT) itself has become fairly well established, and the modality choice should be based on patient clinical status.
When considering HD in AKI due to acute heart failure, the following factors should be taken into account:
- Volume overload unresponsive to diuretics
- Severe metabolic acidosis
- Hyperkalemia
- Uremic symptoms despite optimal medical management The preferred vascular access is a temporary dialysis catheter, and the initial HD sessions should be gentle to avoid hemodynamic instability. Continuous renal replacement therapy (CRRT) may be preferred in hemodynamically unstable patients, as suggested by the 2020 KDIGO conference 1.
The goals of HD in this setting include managing fluid overload, correcting electrolyte abnormalities, and improving acid-base disturbances, which can help reduce cardiac workload and improve oxygenation. However, the timing of HD initiation remains somewhat controversial, and the decision should be individualized based on the patient's specific clinical scenario and response to medical therapy. As stated in the 2020 KDIGO conference 1, the selection of modalities should be considered in the context of available resources and expertise of personnel.
From the Research
Role of Early Hemodialysis in Acute Kidney Injury due to Acute Heart Failure
- The role of early hemodialysis (HD) in acute kidney injury (AKI) due to acute heart failure is complex and depends on various factors, including the severity of AKI and heart failure, as well as the patient's overall clinical condition 2, 3, 4, 5, 6.
- Continuous renal replacement therapy (CRRT) is often used in critically ill patients with AKI, but its association with cardiac stunning has been reported, despite stable hemodynamics 2.
- In patients with acute heart failure who develop AKI, therapeutic decisions, such as reduction or discontinuation of certain medications and fluids administration, can impact renal and clinical outcomes 3.
- The use of diuretics for decongestion in patients with acute heart failure and fluid overload can cause a rise in serum creatinine and AKI, but decongestion therapy can improve survival and prevent hospital admissions in the longer term 5.
- Acute kidney injury is a strong predictor of poor outcomes and early death in patients with pulmonary artery hypertension and acute right-sided heart failure, and extracorporeal ultrafiltration should be reserved for diuretic-resistant individuals 6.
- The principles, modalities, and prescription of CRRT are crucial in the management of severe AKI, and its accurate volume control, steady acid-base, and electrolyte correction can achieve hemodynamic stability 4.