Kidney Week 2025 Annual Meeting-How to Deliver Precision CRRT: Optimizing Dose, Ultrafiltration, and Anticoagulation

Video Transcription

Video Summary

The session focused on delivering “precision” continuous renal replacement therapy (CRRT) by personalizing dose, ultrafiltration (UF), and anticoagulation to patient needs rather than using a fixed recipe.

<strong>CRRT dose:</strong> Landmark trials (ATN, RENAL) showed no mortality benefit to higher-intensity CRRT (35–40 mL/kg/hr) versus standard dosing (20–25 mL/kg/hr), with more complications like hypophosphatemia and hypotension at higher doses. Guidelines recommend delivering 20–25 mL/kg/hr, often prescribing 25–30 to account for downtime. Speakers emphasized “dynamic dosing” over an ICU course (e.g., lower dose when solute control is adequate and complications occur; higher dose for rhabdomyolysis, tumor lysis, refractory hyperkalemia, or toxin clearance). Obesity remains a dosing gray zone; observational data suggest ideal body weight may be preferable to actual/adjusted weight. Emerging work questions whether “low-dose” CRRT may be safe if metabolic control is maintained; trials (e.g., in Germany/Japan) are underway.

<strong>Ultrafiltration and fluid strategy:</strong> Most CRRT starts in patients with fluid overload and/or vasopressor-dependent instability, and cumulative fluid balance strongly relates to outcomes. A key process failure is not setting daily fluid balance targets and not achieving them (“fluid balance gap”). Dr. Mehta argued for targeting <strong>net patient balance</strong> (integrating machine and non-machine inputs/outputs hourly) rather than focusing only on net UF rate, and for linking fluid regulation to hemodynamic monitoring to avoid under-removal (edema) or over-removal (ischemia).

<strong>Anticoagulation:</strong> Anticoagulation is essential for dose delivery and circuit life. Citrate regional anticoagulation is guideline-preferred when no contraindication, with evidence of less bleeding and longer filter life than heparin. Practical RCA requires managing citrate dose vs metabolic load, calcium replacement, and monitoring for citrate accumulation (rising total/ionized calcium ratio, escalating calcium needs, acidosis), especially in severe liver failure or high lactate. Future directions include closed-loop citrate control, sensors, and smarter CRRT platforms.

Asset Subtitle

Moderator(s): David Selewski, Amanda Zeidman

Presentation(s):

Personalized CRRT Dosing: New Frontiers in Precision Medicine - J. Pedro Teixeira
Fluid Balance Reimagined: Hemodynamic Monitoring and Ultrafiltration Precision - Ravindra Mehta
Anticoagulation Excellence: Maximizing Circuit Life While Minimizing Risk - Ashita Tolwani
Innovating CRRT: Technology-Driven Solutions for the Future - Balazs Szamosfalvi

Meta Tag

Date 11/6/2025

Pathway 1 AKI and Critical Care

Pathway 2 Dialysis

Session ID 507008

Keywords

precision CRRT

continuous renal replacement therapy

dynamic CRRT dosing

CRRT dose 20–25 mL/kg/hr

ATN trial

RENAL trial

high-intensity vs standard CRRT

hypophosphatemia

CRRT ultrafiltration strategy

fluid balance gap

net patient balance

hemodynamic monitoring

regional citrate anticoagulation (RCA)

citrate accumulation monitoring

filter life and circuit anticoagulation