Renal replacement therapy in an intensive care unit: guidelines from the SRLF-GFRUP consensus conference

SRLF/GFRUP · 2025 · France

Source and licence

Authors: Mercè Jourdain, Ines Gragueb Chatti, Brahim Housni et al.
Title: Renal replacement therapy in an intensive care unit: guidelines from the SRLF-GFRUP consensus conference
Journal: Annals of Intensive Care, 2025
DOI: 10.1186/s13613-025-01517-0
Licence: CC BY 4.0
Changes: Verbatim excerpts; formatting adapted

Full text retrieved 2026-10-27 from Europe PMC · PMC12267776

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Recommendations

Verbatim, with grade of recommendation or strength of consensus where given.

Methods

After the public meeting, the panel met privately to draft the text answering the questions. Recommendations were formulated according to GRADE methodology. A high quality of evidence led to a strong recommendation for (GRADE 1 +) or against (1-) a specific intervention. A moderate, low or very low quality of evidence led to an optional recommendation for (probably should, 2 +) or against (probably should not, 2-) a specific intervention. In the absence of evidence, no recommendations were made, except where the panel considered a recommendation in the form of a jury opinion (Table 2).

Question 1

Recommendation 1.1There are no data available to define specific clinical or biological threshold criteria, given the lack of studies evaluating the impact of RRT on mortality or the number of patients undergoing dialysis at 28 or 90 days.Panel opinion/Low quality of evidence/Strong agreement
Recommendation 1.1AThe panel suggests initiating urgent RRT in cases of hyperkalemia > 6.5 mmol/L, notwithstanding adequate medical treatment. They suggest considering the following factors when deciding to initiate RRT for hyperkalemia: anuria, a very high risk of worsening hyperkalemia, and/or electrocardiographic changes. The adult recommendation also applies to the pediatric population.Panel opinion/Low quality of evidence/Strong agreement
Recommendation 1.1BThe panel suggests not using metabolic acidosis as the sole criterion for initiating RRT. The adult recommendation also applies to the pediatric population.Panel opinion/Low quality of evidence/Strong agreement
Recommendation 1.1CIn adult patients, the panel suggests initiating RRT in a patient with AKI and volume overload pulmonary edema causing moderate to severe hypoxemia that persists despite adequate medical treatment. In the pediatric population, the panel suggests considering RRT in cases of AKI with fluid overload exceeding 10% of body weight, despite restricted intake and adequate diuretic treatment, based on clinical impact and the benefit-risk balance.Panel opinion/Low quality of evidence/Strong agreement
Recommendation 1.1DThe panel suggests considering RRT when, without signs of renal recovery, blood urea nitrogen concentration exceeds 40 mmol/L (> 2.4 g/L). The adult recommendation also applies to the pediatric population.Panel opinion/Low quality of evidence /Strong agreement
Recommendation 1.1EThe panel suggests not using a plasma creatinine threshold value to initiate RRT. The adult recommendation also applies to the pediatric population.Panel opinion/Low quality of evidence/Strong agreement
Recommendation 1.1FThe panel suggests contacting a toxicology expert center based on the specific circumstances of acute poisoning cases.Panel opinion/Low quality of evidence/Strong agreement
Recommendation 1.2RRT should not be initiated before 72 h in adults with AKI classified as KDIGO 3 in the absence of emergency criteria (e.g., hyperkalemia, severe acidosis, or volume overload pulmonary edema). (Grade 1-/High quality of evidence/Strong agreement). This recommendation also applies to the pediatric population.

Question 2

The different types of RRT (including continuous, intermittent, or hybrid modalities) should probably be considered equivalent in terms of prognostic criteria.Grade 2 + /Moderate quality of evidence/Strong agreement
The panel suggests that the choice of technique should be guided by the expertise of the medical team, the availability of equipment, and its environmental impact.Panel opinion/Low quality of evidence/Strong agreement
Recommendation 2.3APeritoneal Dialysis is probably not recommended for adult patients with AKI when vascular access is available.Grade 2-/Moderate quality of evidence/Strong Agreement
Recommendation 2.3BThe panel suggests that in low and middle-income countries or resource-constrained settings, Peritoneal Dialysis should be considered for adult patients with AKI only if no technique with vascular access is available.Panel opinion/Low quality of evidence/Strong agreement

Question 3

Recommendation 3.1A maximum effluent dose of 25 ml/kg/h during continuous renal replacement therapy, obtained through filtration and/or diffusion, should be prescribed in adults.GRADE 1 + /High quality of evidence/Strong agreement
Recommendation 3.2Daily intermittent hemodialysis aimed at increasing the weekly dialysis dose should probably not be performed. (GRADE 2 + /Moderate quality of evidence/Strong agreement). In the absence of data, no pediatric recommendation can be made.
Recommendation 3.3The panel makes no recommendation concerning rhythm of RRT based on clinical and biological arguments and/or a fixed rhythm of every other day. This applies to the pediatric population.Insufficient quality of evidence/Strong agreement
Recommendation 3.4The panel suggests not exceeding a dialysis dose corresponding to weekly Kt/V of 3.9. (Panel opinion/Low quality of evidence/Strong agreement). As pediatric data are lacking, the panel makes no recommendation.

Question 4

Recommendation 4.1The panel makes no recommendation concerning the choice between portable osmosis device and online ultrapure water for IHD in adults or pediatrics.Panel opinion/Insufficient quality of evidence/Strong agreement
Recommendation 4.2AHigh dialysate sodium concentration should probably be used at initiation of dialysis session to improve hemodynamic tolerance (GRADE 2 + /Moderate quality of evidence/Strong agreement). In pediatrics, the panel makes no recommendationInsufficient quality of evidence
Recommendation 4.2BA cooler dialysate temperature (-1.5 °C to -2 °C below patient’s temperature) should probably be used to improve hemodynamic tolerance (GRADE 2 + /Moderate quality of evidence/Strong agreement). In pediatrics, the panel makes no recommendationInsufficient quality of evidence
Recommendation 4.2CThe panel makes no recommendation regarding reduced blood flow with extended dialysis session to improve hemodynamic tolerance (Insufficient quality of evidence). In pediatrics, the panel makes no recommendationInsufficient quality of evidence
Recommendation 4.3The panel suggests not using devices with online monitoring and automatic biofeedback control for intradialytic blood volume and temperature. (Panel opinion/Low quality of evidence/ Strong agreement). For the pediatric population, the panel makes no recommendation.Insufficient quality of evidence
Recommendation 4.4The panel suggests choosing a low clearance method in patients at risk of intracranial hypertension or with very high blood urea nitrogen to avoid dialysis disequilibrium syndrome. (Panel opinion/Low quality of evidence/Strong agreement). As regards the pediatric population, the panel makes no recommendation.Insufficient quality of evidence
Recommendation 4.5The panel suggests systematically assessing blood volume and not initiating ultrafiltration if clinical evaluation indicates intravascular hypovolemia. The panel suggests stopping ultrafiltration if hypovolemia symptoms arise during RRT. The adult recommendations also apply to the pediatric population.Panel opinion/Low quality of evidence/Strong agreement
Recommendation 4.6The panel suggests not using high cut-off membranes or other specific RRT membranes. (Panel opinion/Low quality of evidence/Strong agreement). The adult recommendations apply to pediatric population. The panel suggests adapting membranes to the child’s weight.Panel opinion/Low quality of evidence/Strong agreement
Recommendation 4.7The panel suggests that continuous veno-venous hemodiafiltration (CVVHDF) improves filter life span compared to continuous veno-venous hemofiltration (CVVHF). (Panel opinion/Low quality of evidence/Strong agreement). As relevant data are lacking, the panel makes no recommendation regarding the efficacy of CVVHDF for purifying small molecules, compared to CVVHF. (Panel opinion/Low quality of evidence/Strong agreement). In pediatrics, the panel makes no recommendationInsufficient quality of evidence

Question 5

Recommendation 5.1AJugular and femoral venous sites should probably be considered equivalent in terms of infectious complications.GRADE2 + /Moderate quality of evidence/Strong agreement
Recommendation 5.1BThe panel makes no recommendation on choice of insertion site for a dialysis catheter to lower the risk of thrombosis.Insufficient quality of evidence/Strong agreement
Recommendation 5.1CIn order of preference, 1) the right internal jugular site 2) the femoral site 3) the left internal jugular site should probably be preferred to lower the risk of dysfunction.GRADE2 + /Moderate quality of evidence/Strong agreement
Recommendation 5.1DThe subclavian route should probably be avoided for the insertion of dialysis catheters unless there is no alternative. This recommendation also applies to the pediatric population.GRADE2-/Moderate quality of evidence/Strong agreement
Recommendation 5.1EIn pediatrics, the panel suggests using the right jugular vein access in children under three years old. In children over three years old, the right jugular vein and a femoral vein access are equivalent. Whatever the patient’s age, the panel suggests respecting a ration size of the catheter/vein diameter < 0.33 in choice of catheter size.Panel opinion/Low quality of evidence/Strong agreement
Recommendation 5.2AThe panel makes no recommendation on the choice of a 4% citrate or heparin lock (≤ 5000 IU/mL) versus a saline lock so as to lower the risk of dysfunction, infection and thrombosis. This recommendation applies to the pediatric population.Panel opinion/Insufficient quality of evidence/Strong agreement
Recommendation 5.2BA high concentration of heparin (> 5000 IU/mL) or citrate (> 4%) should probably not be used to achieve a lock. This recommendation also applies to the pediatric population.GRADE2-/Moderate quality of evidence/Strong agreement
Recommendation 5.2CHeparin locks should probably not be used in patients at risk of hemorrhage. This recommendation also applies to the pediatric population.GRADE2-/Moderate quality of evidence/Strong agreement
Recommendation 5.3AEthanol locks should probably not be used to lower the risk of infection. This recommendation also applies to the pediatric population.GRADE2-/Moderate quality of evidence/Strong agreement
Recommendation 5.3BThe panel makes no recommendation on use of an antibiotic lock to lower the risk of infection. This recommendation also applies to the pediatric population.Panel Opinion/Insufficient quality of evidence/Strong agreement

Question 6

Recommendation 6.1In patients at low risk of bleeding, CRRT with regional citrate anticoagulation should probably be preferred over anticoagulation with unfractionated heparin or low molecular weight heparin. This recommendation also applies to the pediatric population.GRADE 2 + /Moderate quality of evidence/Strong agreement
Recommendation 6.2In patients at high risk of bleeding, in the absence of contraindication to citrate, CRRT with regional citrate anticoagulation should probably be preferred to no anticoagulation. (GRADE 2 + /Moderate quality of evidence/Strong agreement). The panel makes no recommendation regarding the pediatric population.Insufficient quality of evidence/Strong agreement
Recommendation 6.3The panel makes no recommendation regarding the choice of systemic anticoagulation with unfractionated or low molecular weight heparin rather than regional citrate anticoagulation in patients with an indication for IHD and a high risk of bleeding. The panel makes no recommendation regarding the pediatric population.Insufficient quality of evidence/Strong agreement

Question 7

Recommendation 7.1The panel suggests assessing the resumption of diuresis to consider weaning from IHD in AKI. (Panel opinion/Low quality of evidence/Strong agreement). The panel makes no recommendation regarding the pediatric population.
Recommendation 7.2The panel suggests assessment of diuresis resumption when considering weaning from CRRT. This recommendation also applies to the pediatric population.GRADE 2 + /Moderate quality of evidence/Strong agreement
Recommendation 7.3The panel suggests daily assessment of the possibility of weaning from CRRT. If available, IHD can be used as a relay. This recommendation also applies to the pediatric population.Panel opinion/Low quality of evidence/Strong agreement

Abstract

Background: Although largely used, the place of extracorporeal renal replacement therapy (RRT) in acute kidney injury (AKI) in intensive care unit (ICU) patients has yet to be clarified. The French Intensive Care Society (Société de Réanimation de Langue Française, SRLF) and the French Pediatric Group of Intensive Care and Emergency (Groupe Francophone de Réanimation et d’Urgence Pédiatrique, GFRUP) organized a consensus conference in November 2024.

Methods: A committee, without any conflict of interest (CoI) on the subject, defined seven generic questions and drew up a list of sub questions according to the population, intervention, comparison and outcomes (PICO) model. An independent work group reviewed literature using predefined keywords. The quality of the data was assessed using the GRADE methodology. Eighteen experts in the field from both societies proposed their own answers in a public session and answered questions from the jury (a panel of 14 critical-care medicine physicians and a nurse) and the public. The jury then met for 48 h to write out and vote on its recommendations.

Results: The panel provided 45 statements addressing seven questions. In patients, adults or children, admitted to the ICU with AKI (1) What are the indications for RRT, when should it be initiated, and within what timeframe? (2) What are the advantages/disadvantages of the different RRT modalities in ICU, and based on what criteria should they be chosen? (3) Which dose of dialysis should be prescribed for ICU patients? (4) How to prescribe, adjust and monitor each RRT technique? (5) Which vascular access technique should be preferred (insertion site, catheter type and length)? (6) How to prevent circuit thrombosis? (7) What are the criteria to consider weaning from RRT and how can it be achieved?

Conclusions: These recommendations should optimize the prescription and use of RRT during AKI in ICUs for both adult and pediatric patients.

Supplementary Information: The online version contains supplementary material available at 10.1186/s13613-025-01517-0.

Contents of the original publication

The section headings of the original.

Introduction and background
Methods
Section 1: RRT indications and time frame
Question 1
Section 2: Different RRT modalities and modalities of prescription
Question 2
Question 3
Question 4
Section 3 Technical aspects
Question 5
Section 4: Anticoagulation
Question 6
Section 5: RRT weaning
Question 7

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