New Clinical Guidelines Standardize Kidney Replacement Therapy in ICU Patients
核心洞察
The Chinese Society of Critical Care Medicine (搜索) published a clinical practice guideline for renal replacement therapy in adult ICU patients with acute kidney injury (搜索), released online August 18, 2026 in the Journal of Intensive Medicine.
The guideline offers 34 recommendations across seven domains and 29 clinical questions, covering RRT initiation timing, vascular access, modality selection, membrane filters, anticoagulation, replacement fluid and weaning.
Recommendations were graded strong or weak using the GRADE approach, with regional citrate anticoagulation (搜索) strongly recommended as first-line for continuous renal replacement therapy in patients without bleeding risk.
Up to 50 to 60 percent of ICU patients develop acute kidney injury (搜索), and roughly 10 to 15 percent progress to severe stages requiring renal replacement therapy (RRT). Despite decades of clinical use, no unified standard has existed for when to start or stop RRT, which modality to choose, or how to manage anticoagulation in this hemodynamically unstable population.
The Chinese Society of Critical Care Medicine (搜索) convened a multidisciplinary expert panel and developed a clinical practice guideline using the GRADE approach, drawing on systematic literature retrieval, meta-analysis and evidence synthesis. Published online on August 18, 2026 in the Journal of Intensive Medicine, it sets out 34 recommendations across seven domains organized around 29 clinical questions, and applies only to adult critically ill patients. The authors reviewed the RIFLE, AKIN and KDIGO systems for AKI diagnosis and classification.
Strong recommendations include ultrasound evaluation, localization and real-time ultrasound-guided puncture when establishing RRT vascular access, and regional citrate anticoagulation (搜索) (RCA) as first-line anticoagulation for continuous renal replacement therapy (CRRT) in patients without bleeding risk. For patients without bleeding risk but with risk of citrate accumulation, heparin is strongly recommended first-line; RCA remains first-line for those with bleeding risk. The guideline advises initiating RRT as early as possible in life-threatening fluid overload, electrolyte disturbance or acid-base imbalance, and not delaying it when blood urea nitrogen (搜索) exceeds 40 millimolars per liter or uremic encephalopathy (搜索) is present. Catheterization may use the right internal jugular or femoral vein. Either continuous or intermittent RRT may be selected based on clinical condition and treatment goals, and trial discontinuation is suggested when urine output recovers above 600 mL in 24 hours the day prior or above 1000 mL in 24 hours on the day of liberation.