Proceedings of the University of Alabama at Birmingham Continuous Renal Replacement Therapy Academy (2023-2024): Managing De-Escalation of Acute Renal Replacement Therapy and Optimizing Drug Dosing during Renal Replacement Therapy Transitions.

In this second installment of the proceedings of the University of Alabama at Birmingham Continuous Renal Replacement Therapy (CRRT) Academy, we focus on the topic of transitions of care in acute renal replacement therapy (RRT). Although we have accumulated data from thousands of critically ill patients with AKI randomized to different strategies for RRT initiation, no trial data exist to guide de-escalation of RRT in the intensive care unit. However, for survivors of severe AKI whose kidney function does not recovery rapidly enough to allow for liberation directly from CRRT, successful de-escalation of care requires the transition from CRRT to intermittent RRT modalities. These transition periods must be carefully navigated since they can be a source of complications, such as failure to transition or intradialytic hypotension, which are in turn associated with an increased risk of mortality and reduced odds of kidney recovery. In this review, we focus on the critical factors to consider during de-escalation of RRT care, with a focus on modality transition, the role of volume status in guiding the approach to de-escalation of RRT, and the vital importance of careful dosing of drugs, especially antimicrobial agents, during this transitional period.