What are the criteria for discontinuing Triple-Phase Renal Transplant Rejection (TRRC) treatment?

Criteria for Discontinuing Continuous Renal Replacement Therapy (CRRT)

Urine output is the most validated parameter for determining when to discontinue CRRT, with specific thresholds of >400 mL/24h without diuretics and >2000 mL/24h with diuretics being recommended for successful discontinuation. 1

Primary Parameters for CRRT Discontinuation

Urine Output Assessment

• Without diuretics: Discontinue when urine output exceeds 400 mL/24h
• With diuretics: Higher threshold required - approximately 2000 mL/24h
• Predictive accuracy: Pooled sensitivity of 66.2% and specificity of 73.6% for successful discontinuation 1

Kidney Function Recovery

• Discontinue when intrinsic kidney function has recovered sufficiently to meet patient needs 2
• Monitor serum creatinine trends - improvement indicates potential for successful discontinuation
• Consider kinetic eGFR on the first day post-discontinuation (combined with urine output has AUROC 0.93) 2

Monitoring Protocol After CRRT Discontinuation

1. Daily urine output tracking:

   • Document at consistent timepoints relative to discontinuation
   • Watch for declining trends which may indicate need for restart

2. Serum creatinine monitoring:

   • Calculate incremental creatinine ratio (day 2/day 0)
   • Ratio ≥1.5 indicates high risk of requiring RRT restart 1

3. Fluid balance assessment:

   • Monitor for signs of fluid overload
   • Assess patient's ability to maintain appropriate fluid status without CRRT

Risk Stratification for Failed Discontinuation

The risk of experiencing progressive deterioration after CRRT discontinuation correlates with pre-discontinuation serum creatinine levels 2:

• Serum creatinine ≤3 mg/dL: 3% risk of failure
• Serum creatinine 3.1-5 mg/dL: 16% risk of failure
• Serum creatinine >5 mg/dL: 23% risk of failure

Special Considerations

• Diuretic challenge: Consider in patients with borderline urine output, but be aware this reduces predictive accuracy of urine output measurements 1
• Failed discontinuation consequences: Associated with higher hospital mortality 1
• Multivariate approach: The most promising model combines urine output on discontinuation day with kinetic eGFR on first day post-discontinuation 2

Pitfalls to Avoid

1. Premature discontinuation: Can lead to worsened physiologic profiles, fluid accumulation, metabolic acidosis, and retention of metabolic waste 2

2. Relying solely on single parameters: Use a combination of urine output, creatinine trends, and clinical status rather than single thresholds alone 2

3. Inconsistent monitoring: Failure to assess parameters at consistent timepoints can lead to missed opportunities for early intervention if kidney function deteriorates

4. Ignoring the effect of diuretics: Diuretics significantly alter the predictive thresholds for urine output and must be accounted for in decision-making 1

5. Delayed recognition of failed discontinuation: Have clear criteria for when to restart CRRT if needed

By following these evidence-based criteria for CRRT discontinuation, clinicians can optimize the timing of liberation from renal replacement therapy while minimizing the risks associated with both premature discontinuation and unnecessary continuation.