Topic

Nephrology in critical care

Timing of renal replacement therapy and fluid choice.

Wait before starting dialysis. Accelerated initiation did not reduce mortality and left more patients dialysis-dependent at 90 days (STARRT-AKI); many in the standard arm never needed dialysis at all. There is a limit to that patience — postponing further than a delayed strategy caused harm without benefit (AKIKI 2). Once started, dialysing less often was associated with faster recovery of kidney function (LIBERATE-D).

Modality does not matter provided the delivery is careful: intermittent haemodialysis matched continuous therapy for survival in multi-organ failure (Hemodiafe).

Balanced fluid is not better than saline. The physiological case against chloride-rich fluid was strong, and two large trials found the clinical difference negligible (PLUS, BaSICS).

Choice of crystalloid

Trial	Year	Therapy	Effect	Finding
PLUS	2022	Balanced multielectrolyte solution		Balanced fluid was no better than saline in critically ill adults
BaSICS	2021	Balanced solution		Balanced solution did not improve survival over saline in over ten thousand patients

When to start dialysis

Trial	Year	Therapy	Effect	Finding
AKIKI 2	2021	More-delayed initiation		Waiting even longer than a delayed strategy caused harm without benefit
STARRT-AKI	2020	Accelerated initiation		Starting dialysis early did not save lives and left more patients dialysis-dependent

Continuous or intermittent dialysis

Trial	Year	Therapy	Effect	Finding
Hemodiafe	2006	Intermittent haemodialysis		Intermittent haemodialysis matched continuous therapy when delivered carefully

Dialysis intensity and recovery

Trial	Year	Therapy	Effect	Finding
LIBERATE-D	2026	Conservative dialysis strategy		Dialysing less often led to faster recovery of kidney function and less hypotension

Key references

Guidelines, standards and reviews for this topic.