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Claudio Ronco - One of the best experts on this subject based on the ideXlab platform.
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Renal Replacement Therapy
Critical Care Clinics, 2015Co-Authors: Gianluca Villa, Zaccaria Ricci, Claudio RoncoAbstract:Renal Replacement Therapy (RRT) is a cornerstone in the clinical management of patients with acute kidney injury. Results from different studies agree that early Renal support Therapy (aimed to support the residual kidney function during early phases of organ dysfunction) may reduce mortality with respect to late RRT (aimed to substitute the complete loss of function during the advanced kidney insufficiency). Although it seems plausible that a timely initiation of RRT may be associated with improved Renal and nonRenal outcomes in these patients, there is scarce evidence in literature to exactly identify the most adequate onset timing for RRT.
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Renal Replacement Therapy
Critical Care Clinics, 2015Co-Authors: Gianluca Villa, Zaccaria Ricci, Claudio RoncoAbstract:Endogenous toxins accumulate in blood as a result of many biochemical processes.1 If their concentration exceeds certain levels, they cause illness. Some toxins are volatile (e.g., CO2, ketones) and can be excreted by the lungs through ventilation; others are lipophilic (e.g., bile acids, bilirubin) and can be excreted by the liver via the biliary system; yet others are water soluble and nonvolatile and are excreted by the kidneys.2 When acute kidney injury (AKI) occurs, these water-soluble substances (potassium, phosphate, urea, creatinine) and endogenous toxins (methylguanidine, guanidinosuccinic acid, hippuric acid, uric acid, phenols, beta-2 microglobulin, purines, myo-inositol, etc.), which are normally excreted by the kidney, accumulate in blood. If accumulation progresses, AKI becomes severe; and if their removal is not addressed by either Renal recovery or the initiation of artificial Renal Replacement Therapy, the patient dies from uncontrolled hyperkalemia or uremia. Unfortunately, AKI requiring Renal Replacement Therapy (RRT) is relatively common in critically ill patients treated in the intensive care unit (ICU) and involves close to 5% of all admissions.3 When a decision is made that artificial Renal Replacement Therapy is needed, the physician has a variety of techniques at his/her disposal: intermittent hemodialysis (IHD), continuous Renal Replacement Therapy (CCRT), slow extended daily dialysis (SLEDD), and peritoneal dialysis, each with its technical variations. All of these techniques rely on the principle that unwanted solutes and water can be removed through a semipermeable membrane-based separating process. The principles of such process have been extensively studied and described.4,5
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dose and efficiency of Renal Replacement Therapy continuous Renal Replacement Therapy versus intermittent hemodialysis versus slow extended daily dialysis
Critical Care Medicine, 2008Co-Authors: Zaccaria Ricci, Claudio RoncoAbstract:Acute kidney injury represents an independent risk of death in the intensive care unit and significantly contributes to in-hospital mortality. The only accepted treatment of severe acute kidney injury so far is Renal Replacement Therapy, which is not a causative Therapy but rather a life-support tre
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Dose and efficiency of Renal Replacement Therapy: continuous Renal Replacement Therapy versus intermittent hemodialysis versus slow extended daily dialysis.
Critical care medicine, 2008Co-Authors: Zaccaria Ricci, Claudio RoncoAbstract:Acute kidney injury represents an independent risk of death in the intensive care unit and significantly contributes to in-hospital mortality. The only accepted treatment of severe acute kidney injury so far is Renal Replacement Therapy, which is not a causative Therapy but rather a life-support treatment. Renal Replacement Therapy can be performed by several different techniques: intermittent hemodialysis, slow extended daily dialysis, peritoneal dialysis, or continuous Renal Replacement Therapy. There is controversy about which technique should be used, which dosage should be selected for each Therapy, and whether the technique and/or the dose of Renal Replacement Therapy may impact survival in critically ill patients. After a careful review of the recent literature, definitive conclusions cannot be drawn: Trials are in most cases underpowered and conducted over many years, in which significant changes in the practice of acute dialytic techniques have taken place. Other studies have described therapeutic modalities requiring a high level of specific expertise in the field and generally not easily reproducible in the routine practice. While practitioners are waiting for the ultimate trial to be published, we think it is worth reporting some broad concepts and few suggestions for Renal Replacement Therapy prescription derived from current evidence and from the available experience.
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the first international consensus conference on continuous Renal Replacement Therapy
Kidney International, 2002Co-Authors: John A Kellum, Ravindra L. Mehta, Paul M. Palevsky, Derek C Angus, Claudio RoncoAbstract:The first international consensus conference on continuous Renal Replacement Therapy. Background Management of acute Renal failure (ARF) in the critically ill is extremely variable and there are no published standards for the provision of Renal Replacement Therapy in this population. We sought to review the available evidence, make evidence-based practice recommendations, and delineate key questions for future study. Methods We undertook an evidence-based review of the literature on continuous Renal Replacement Therapy (CRRT) using MEDLINE searches. We determined a list of key questions and convened a 2-day consensus conference to develop summary statements via a series of alternating breakout and plenary sessions. In these sessions, we identified supporting evidence and generated practice guidelines and/or directions for future research. Results Of the 46 questions considered, we found consensus for 20. We found inadequate evidence for 21 questions and for the remaining five we found data but no consensus. Full versions of workgroup findings are available on the Internet at http://www.ADQI.net. Conclusions Despite limited data, broad areas of consensus exist for use of CRRT and guideline development appears feasible. Equally broad areas of disagreement also exist and additional basic and applied research in acute Renal failure is needed.
Zaccaria Ricci - One of the best experts on this subject based on the ideXlab platform.
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Renal Replacement Therapy
Critical Care Clinics, 2015Co-Authors: Gianluca Villa, Zaccaria Ricci, Claudio RoncoAbstract:Renal Replacement Therapy (RRT) is a cornerstone in the clinical management of patients with acute kidney injury. Results from different studies agree that early Renal support Therapy (aimed to support the residual kidney function during early phases of organ dysfunction) may reduce mortality with respect to late RRT (aimed to substitute the complete loss of function during the advanced kidney insufficiency). Although it seems plausible that a timely initiation of RRT may be associated with improved Renal and nonRenal outcomes in these patients, there is scarce evidence in literature to exactly identify the most adequate onset timing for RRT.
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Renal Replacement Therapy
Critical Care Clinics, 2015Co-Authors: Gianluca Villa, Zaccaria Ricci, Claudio RoncoAbstract:Endogenous toxins accumulate in blood as a result of many biochemical processes.1 If their concentration exceeds certain levels, they cause illness. Some toxins are volatile (e.g., CO2, ketones) and can be excreted by the lungs through ventilation; others are lipophilic (e.g., bile acids, bilirubin) and can be excreted by the liver via the biliary system; yet others are water soluble and nonvolatile and are excreted by the kidneys.2 When acute kidney injury (AKI) occurs, these water-soluble substances (potassium, phosphate, urea, creatinine) and endogenous toxins (methylguanidine, guanidinosuccinic acid, hippuric acid, uric acid, phenols, beta-2 microglobulin, purines, myo-inositol, etc.), which are normally excreted by the kidney, accumulate in blood. If accumulation progresses, AKI becomes severe; and if their removal is not addressed by either Renal recovery or the initiation of artificial Renal Replacement Therapy, the patient dies from uncontrolled hyperkalemia or uremia. Unfortunately, AKI requiring Renal Replacement Therapy (RRT) is relatively common in critically ill patients treated in the intensive care unit (ICU) and involves close to 5% of all admissions.3 When a decision is made that artificial Renal Replacement Therapy is needed, the physician has a variety of techniques at his/her disposal: intermittent hemodialysis (IHD), continuous Renal Replacement Therapy (CCRT), slow extended daily dialysis (SLEDD), and peritoneal dialysis, each with its technical variations. All of these techniques rely on the principle that unwanted solutes and water can be removed through a semipermeable membrane-based separating process. The principles of such process have been extensively studied and described.4,5
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dose and efficiency of Renal Replacement Therapy continuous Renal Replacement Therapy versus intermittent hemodialysis versus slow extended daily dialysis
Critical Care Medicine, 2008Co-Authors: Zaccaria Ricci, Claudio RoncoAbstract:Acute kidney injury represents an independent risk of death in the intensive care unit and significantly contributes to in-hospital mortality. The only accepted treatment of severe acute kidney injury so far is Renal Replacement Therapy, which is not a causative Therapy but rather a life-support tre
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Dose and efficiency of Renal Replacement Therapy: continuous Renal Replacement Therapy versus intermittent hemodialysis versus slow extended daily dialysis.
Critical care medicine, 2008Co-Authors: Zaccaria Ricci, Claudio RoncoAbstract:Acute kidney injury represents an independent risk of death in the intensive care unit and significantly contributes to in-hospital mortality. The only accepted treatment of severe acute kidney injury so far is Renal Replacement Therapy, which is not a causative Therapy but rather a life-support treatment. Renal Replacement Therapy can be performed by several different techniques: intermittent hemodialysis, slow extended daily dialysis, peritoneal dialysis, or continuous Renal Replacement Therapy. There is controversy about which technique should be used, which dosage should be selected for each Therapy, and whether the technique and/or the dose of Renal Replacement Therapy may impact survival in critically ill patients. After a careful review of the recent literature, definitive conclusions cannot be drawn: Trials are in most cases underpowered and conducted over many years, in which significant changes in the practice of acute dialytic techniques have taken place. Other studies have described therapeutic modalities requiring a high level of specific expertise in the field and generally not easily reproducible in the routine practice. While practitioners are waiting for the ultimate trial to be published, we think it is worth reporting some broad concepts and few suggestions for Renal Replacement Therapy prescription derived from current evidence and from the available experience.
Rinaldo Bellomo - One of the best experts on this subject based on the ideXlab platform.
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timing of initiation of Renal Replacement Therapy in acute kidney injury
The New England Journal of Medicine, 2020Co-Authors: Starrt-aki Investigators, Ron Wald, Rinaldo Bellomo, Stephane Gaudry, Sean M Bagshaw, N K Adhikari, Bruno R Da Costa, Didier Dreyfuss, Martin Gallagher, Eric HosteAbstract:Background Acute kidney injury is common in critically ill patients, many of whom receive Renal-Replacement Therapy. However, the most effective timing for the initiation of such Therapy remains uncertain. Methods We conducted a multinational, randomized, controlled trial involving critically ill patients with severe acute kidney injury. Patients were randomly assigned to receive an accelerated strategy of Renal-Replacement Therapy (in which Therapy was initiated within 12 hours after the patient had met eligibility criteria) or a standard strategy (in which Renal-Replacement Therapy was discouraged unless conventional indications developed or acute kidney injury persisted for >72 hours). The primary outcome was death from any cause at 90 days. Results Of the 3019 patients who had undergone randomization, 2927 (97.0%) were included in the modified intention-to-treat analysis (1465 in the accelerated-strategy group and 1462 in the standard-strategy group). Of these patients, Renal-Replacement Therapy was performed in 1418 (96.8%) in the accelerated-strategy group and in 903 (61.8%) in the standard-strategy group. At 90 days, death had occurred in 643 patients (43.9%) in the accelerated-strategy group and in 639 (43.7%) in the standard-strategy group (relative risk, 1.00; 95% confidence interval [CI], 0.93 to 1.09; P = 0.92). Among survivors at 90 days, continued dependence on Renal-Replacement Therapy was confirmed in 85 of 814 patients (10.4%) in the accelerated-strategy group and in 49 of 815 patients (6.0%) in the standard-strategy group (relative risk, 1.74; 95% CI, 1.24 to 2.43). Adverse events occurred in 346 of 1503 patients (23.0%) in the accelerated-strategy group and in 245 of 1489 patients (16.5%) in the standard-strategy group (P Conclusions Among critically ill patients with acute kidney injury, an accelerated Renal-Replacement strategy was not associated with a lower risk of death at 90 days than a standard strategy. (Funded by the Canadian Institutes of Health Research and others; STARRT-AKI ClinicalTrials.gov number, NCT02568722.).
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Circuit Hemodynamics and Circuit Failure During Continuous Renal Replacement Therapy.
Critical care medicine, 2019Co-Authors: Benjamin Sansom, Shyamala Sriram, Jeffrey J. Presneill, Rinaldo BellomoAbstract:Objectives:To study hemodynamic changes within continuous Renal Replacement Therapy circuits and evaluate their relationship with continuous Renal Replacement Therapy longevity.Design:Analysis of downloaded variables recorded by continuous Renal Replacement Therapy machines during multiple episodes
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Renal Replacement Therapy in the ICU: intermittent hemodialysis, sustained low-efficiency dialysis or continuous Renal Replacement Therapy?
Current opinion in critical care, 2018Co-Authors: Amanda Y. Wang, Rinaldo BellomoAbstract:Purpose of reviewSevere acute kidney injury in the ICU setting often requires Renal Replacement Therapy (RRT). Intermittent hemodialysis (IHD), hybrid forms of RRT such as sustained low-efficiency dialysis (SLED), as well as continuous Renal Replacement Therapy (CRRT) are the three common modalities
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Continuous Renal Replacement Therapy: recent advances and future research
Nature Reviews Nephrology, 2010Co-Authors: John R. Prowle, Rinaldo BellomoAbstract:Continuous Renal Replacement Therapy (CRRT) is the preferred treatment for acute kidney injury (AKI) in intensive care units (ICUs) throughout much of the developed world. Despite its widespread use, however, no formal proof exists that patient outcomes are improved when CRRT is used in preference to intermittent hemodialysis (IHD). In addition, controversy and center-specific practice variation in the clinical application of CRRT continues, owing to a lack of randomized multicenter studies of both CRRT and IHD providing level 1 data to inform clinical practice. Now, however, the publication of results from the Veterans Affairs/National Institutes of Health Acute Renal Failure Trial Network (ATN) study and the Randomized Evaluation of Normal versus Augmented Level Renal Replacement Therapy (Renal) trial have provided an unparalleled quantity of information to guide clinicians. These pivotal trials investigated different intensities of CRRT in the ICU and provided level 1 evidence that effluent flow rates >25 ml/kg per hour do not improve outcomes in patients in the ICU. In this Review, we discuss the background and results of the ATN and Renal trials and the emerging consensus that CRRT is the most appropriate treatment for AKI in vasopressor-dependent patients in the ICU. Finally, we describe the remaining controversies regarding the use of CRRT and the questions that remain to be answered. Although continuous Renal Replacement Therapy (CRRT) is widely used for the treatment of acute kidney injury in intensive care units, controversy in the clinical application of this Therapy continues. Results of two recently published randomized controlled trials—the ATN study and the Renal trial—have now provided an unparalleled quantity of information to guide clinicians. Here, Prowle and Bellomo discuss the results of these trials, explain the controversies that still exist regarding the use of CRRT, and describe the questions that remain to be answered. Continuous Renal Replacement Therapy (CRRT) is now the leading form of Renal Replacement Therapy for acute kidney injury (AKI) in intensive care units (ICUs) worldwide Practice variation in the application of CRRT remains considerable owing to the absence of clear evidence-based guidelines Two large, multicenter, randomized controlled trials have now established that increasing the dose of CRRT above an effluent flow rate of 25 ml/kg per hour is not beneficial CRRT is now widely accepted as the most appropriate Therapy for vasopressor-dependent patients who require Renal Replacement Therapy for AKI in the ICU A number of aspects of CRRT require further research, particularly the optimal threshold and timing of CRRT Factors such as local experience and cost will probably continue to determine choice of Therapy in different regions
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intensity of continuous Renal Replacement Therapy in critically ill patients
The New England Journal of Medicine, 2009Co-Authors: Rinaldo Bellomo, Alan Cass, Louise Cole, Simon Finfer, Shay Mcguinness, John Myburgh, Martin Gallagher, Colin Mcarthur, Robyn Norton, Carlos ScheinkestelAbstract:Background The optimal intensity of continuous Renal-Replacement Therapy remains unclear. We conducted a multicenter, randomized trial to compare the effect of this Therapy, delivered at two different levels of intensity, on 90-day mortality among critically ill patients with acute kidney injury. Methods We randomly assigned critically ill adults with acute kidney injury to continuous Renal-Replacement Therapy in the form of postdilution continuous venovenous hemodiafiltration with an effluent flow of either 40 ml per kilogram of body weight per hour (higher intensity) or 25 ml per kilogram per hour (lower intensity). The primary outcome measure was death within 90 days after randomization. Results Of the 1508 enrolled patients, 747 were randomly assigned to higher-intensity Therapy, and 761 to lower-intensity Therapy with continuous venovenous hemodiafiltration. Data on primary outcomes were available for 1464 patients (97.1%): 721 in the higher-intensity group and 743 in the lower-intensity group. The two study groups had similar baseline characteristics and received the study treatment for an average of 6.3 and 5.9 days, respectively (P = 0.35). At 90 days after randomization, 322 deaths had occurred in the higher-intensity group and 332 deaths in the lower-intensity group, for a mortality of 44.7% in each group (odds ratio, 1.00; 95% confidence interval [CI], 0.81 to 1.23; P = 0.99). At 90 days, 6.8% of survivors in the higher-intensity group (27 of 399), as compared with 4.4% of survivors in the lower-intensity group (18 of 411), were still receiving Renal-Replacement Therapy (odds ratio, 1.59; 95% CI, 0.86 to 2.92; P = 0.14). Hypophosphatemia was more common in the higher-intensity group than in the lower-intensity group (65% vs. 54%, P Conclusions In critically ill patients with acute kidney injury, treatment with higher-intensity continuous Renal-Replacement Therapy did not reduce mortality at 90 days. (ClinicalTrials.gov number, NCT00221013.)
Heleen M. Oudemans-van Straaten - One of the best experts on this subject based on the ideXlab platform.
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Primum non nocere, safety of continuous Renal Replacement Therapy.
Current Opinion in Critical Care, 2007Co-Authors: Heleen M. Oudemans-van StraatenAbstract:PURPOSE OF REVIEW: To highlight selected adverse effects of continuous Renal Replacement Therapy and to suggest measures for reducing harm. RECENT FINDINGS: Adverse effects of continuous Renal Replacement Therapy are related to bioincompatibility, bleeding, metabolic consequences, loss of heat, vascular access and human error. Bioincompatibility initiates coagulation and inflammation. Use of membranes with high pore size permits direct removal of the locally formed inflammatory mediators. Regional anticoagulation with citrate reduces the risk of bleeding and abolishes polymorphonuclear and platelet degranulation in the filter. Continuous Renal Replacement Therapy is associated with increased losses of amino acids and the water-soluble vitamins carnitine and selenium. Compared to bicarbonate, lactate-buffered fluids may increase energy needs and glucose intolerance. Patients on continuous Renal Replacement Therapy may lose heat. SUMMARY: Several measures can be considered to improve safety of continuous Renal Replacement Therapy. Among these are the use of membranes with high pore size, implementation of citrate to reduce bleeding and bioincompatibility, supplementation of water-soluble vitamins and selenium to increase antioxidant defense, use of bicarbonate-buffered solutions in the most critically ill, and prevention of loss of heat. Last but not least, improvement of safety needs continuous training of staff for better understanding of the method.
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Primum non nocere, safety of continuous Renal Replacement Therapy.
Current opinion in critical care, 2007Co-Authors: Heleen M. Oudemans-van StraatenAbstract:Purpose of reviewTo highlight selected adverse effects of continuous Renal Replacement Therapy and to suggest measures for reducing harm.Recent findingsAdverse effects of continuous Renal Replacement Therapy are related to bioincompatibility, bleeding, metabolic consequences, loss of heat, vascular
Paul M. Palevsky - One of the best experts on this subject based on the ideXlab platform.
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continuous Renal Replacement Therapy who when why and how
Chest, 2019Co-Authors: Srijan Tandukar, Paul M. PalevskyAbstract:Continuous Renal Replacement Therapy (CRRT) is commonly used to provide Renal support for critically ill patients with acute kidney injury, particularly patients who are hemodynamically unstable. A variety of techniques that differ in their mode of solute clearance may be used, including continuous venovenous hemofiltration with predominantly convective solute clearance, continuous venovenous hemodialysis with predominantly diffusive solute clearance, and continuous venovenous hemodiafiltration, which combines both dialysis and hemofiltration. The present article compares CRRT with other modalities of Renal support and reviews indications for initiation of Renal Replacement Therapy, as well as dosing and technical aspects in the management of CRRT.
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Acute Renal Replacement Therapy during hospitalization: Is training adequate?
Seminars in dialysis, 2018Co-Authors: Paul M. PalevskyAbstract:Acute Renal Replacement Therapy is one of the most common interventions provided by nephrologists, however, data on the quality of training provided to nephrology fellows is limited. Extensive curricula for acute Renal Replacement Therapy and the management of poisonings and intoxications have been published, but personal experience suggests that there are significant opportunities to improve training. Particular areas to be considered include the use of novel technologies for assessment of volume status, greater emphasis on the dosing of medications during acute Renal Replacement Therapy, greater training in assessing and tailoring treatment to the goals of care of the individual patient, incorporation of continuous quality improvement tools into the management of acute Renal Replacement Therapy programs and development of robust simulation training to augment training.
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Dosing of Renal Replacement Therapy in Acute Kidney Injury
American journal of kidney diseases : the official journal of the National Kidney Foundation, 2012Co-Authors: Anitha Vijayan, Paul M. PalevskyAbstract:The impact of the intensity of Renal Replacement Therapy on outcomes in patients with acute kidney injury has been studied intensively during the past decade. In this review, we consider the concept of dose of Renal Replacement Therapy in acute kidney injury and summarize the recent clinical trials addressing this topic. Although several single-center trials suggest that more intensive Therapy is associated with improved outcomes, 2 large multicenter randomized trials do not find a benefit with higher doses of Therapy. Based on these studies, we provide recommendations for the delivered intensity of Renal Replacement Therapy in acute kidney injury.
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Indications and timing of Renal Replacement Therapy in acute kidney injury.
Critical Care Medicine, 2008Co-Authors: Paul M. PalevskyAbstract:The optimal timing for initiation of Renal Replacement Therapy in patients with acute kidney injury remains uncertain. Conventionally accepted indications include volume overload, hyperkalemia, metabolic acidosis, overt uremia, and even progressive azotemia in the absence of specific symptoms; however, precise definitions for these indications are lacking. Data from recent observational trials have suggested that early initiation of Renal Replacement Therapy may be associated with decreased mortality; however, the results of these studies are inconclusive. Existing data on timing of initiation of Renal Replacement Therapy in acute kidney injury that guide current clinical practice are summarized and issues that need to be addressed in future clinical trials are discussed.
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Renal Replacement Therapy I: Indications and Timing
Critical care clinics, 2005Co-Authors: Paul M. PalevskyAbstract:The indications for initiation of Renal Replacement Therapy in acute Renal failure are controversial. Although volume overload, metabolic acidosis, hyperkalemia and other electrolyte disturbances, and overt uremic manifestations are commonly accepted indications for Renal Replacement Therapy, specific criteria for initiation of Therapy based on these conditions are highly subjective. Progressive azotemia in the absence of overt uremia is another common indication for Renal Replacement Therapy although there is no consensus on the degree of azotemia that warrants initiation of Therapy. The clinical data regarding timing and initiation of Renal support in patients who have acute Renal failure are reviewed. Definitive resolution of the appropriate indications and timing for initiation of Renal Replacement Therapy in acute Renal failure requires prospective evaluation in a randomized clinical trial.