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Review Article
Nephrology Dialysis decision in critically ill patients in intensive care unit
Harin Rhee1,2orcid
Acute and Critical Care 2025;40(1):1-9.
DOI: https://doi.org/10.4266/acc.004896
Published online: February 28, 2025

1Department of Nephrology, Pusan National University School of Medicine, Yangsan, Korea

2Biomedical Research Institute, Pusan National University Hospital, Busan, Korea

Corresponding author: Harin Rhee Department of Nephrology, Pusan National University School of Medicine and Biomedical Research Institute, Pusan National University Hospital, 179 Gudeok-ro, Seo-gu, Busan 49241, Korea Tel: +82-51-240-7225, Fax: +82-51-254-3127 E-mail: rheeharin@pusan.ac.kr
• Received: December 25, 2024   • Revised: February 1, 2025   • Accepted: February 6, 2025

© 2025 The Korean Society of Critical Care Medicine

This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

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  • The 2012 Kidney Disease Improving Global Outcomes guidelines clearly define emergent indications for kidney replacement therapy; however, whether dialysis should be initiated in critically ill patients without these indications remains unclear. This review briefly summarizes the results of recent landmark trials and discusses their limitations originating from a criteria-based approach at a single time point. Moreover, a personalized approach based on each patient’s demand-capacity balance and its future benefits as a platform for kidney support therapy in critically ill patients are discussed.
  • Key Words: acute kidney injury; critical illness; kidney replacement therapy; kidney support therapy; time-to-treatment
Acute kidney injury (AKI) is a common yet potentially fatal condition in intensive care units (ICUs). The incidence of AKI in the ICU is reported to be 20%–40% [1-3] with a variable mortality rate of approximately 20%–50% [1,3]. Progression to chronic kidney disease (CKD) or end-stage kidney disease is common in AKI survivors [4,5], which requires tailored follow-up after discharge. Acute dialysis is the cornerstone of treatment in these patients; nevertheless, vascular access-associated complications, such as bleeding or bloodstream infection, must be considered as potential adverse effects. The 2012 Kidney Disease Improving Global Outcomes (KDIGO) guidelines state that kidney replacement therapy (KRT) should be initiated emergently when life-threatening changes in fluid, electrolyte, and acid-base balance occur; however, in clinical situations without life-threatening changes, the initiation of KRT needs to be considered based on the broader clinical context, the presence of conditions that can be modified with KRT, and trends of laboratory tests [6]. These statements were not graded because the guidelines were based on common sense rather than sufficient evidence. At that time, the establishment of reproducible criteria to guide the timing of KRT initiation as well as evidence for whether early or late initiation improves outcomes, remained unknown [6]. Several randomized controlled trials (RCTs) have attempted to identify reproducible and clear indications for urgent dialysis. However, these criteria-based approaches have certain limitations.
This review briefly summarizes the recent RCTs on KRT initiation (criteria-based approach) and introduces the concept of a personalized approach to KRT initiation (Figure 1). Studies on KRT modality selection and the recent status of kidney/organ supportive therapy, including hemoadsorption, are also summarized.
Criteria-Based Approach: Summary of Recent RCTs
The ELAIN (early versus Late initiation of renal replacement therapy in critically ill patients with acute kidney injury) study [7] was the first published study that was performed in a single center in Germany and included 231 patients with predominant ICU admission after cardiac surgery. The inclusion criteria were AKI stage 2 (increase in serum creatinine to 2–2.9 times baseline, or urine output <0.5 ml/kg sustained for ≥12 hours), plasma neutrophil gelatinase-associated lipocalin levels >150 mg/ml, and one of the following conditions: sepsis, vasopressor or catecholamine use, refractory volume overload, and/or manifestation of non-kidney organ dysfunction. Early initiation was defined as the initiation of dialysis within 8 hours of randomization, and delayed initiation as dialysis within 12 hours of AKI stage 3 (increase in serum creatinine higher than three times baseline, decrease in urine output to <0.3 ml/kg for ≥24 hours, or anuria sustained for ≥12 hours). At the time of randomization, median fluid accumulation was 6.8 L in early group and 6.3 L in delayed group. Nearly all patients, except for 9% in the delayed group, received KRT with dialysis as continuous kidney replacement therapy (CKRT). The primary outcome was 90-day mortality, and early initiation reduced mortality by 33% (hazard ratio [HR], 0.66; 95% CI, 0.45–0.97).
The Artificial Kidney Initiation in Kidney Injury (AKIKI) study [8], a multicenter study conducted in France, enrolled 620 patients with AKI stage 3 receiving invasive mechanical ventilation, catecholamine infusion, or both. The early group received KRT within 6 hours of documentation of stage 3 AKI, and the delayed group received KRT in the presence of urgent indications (blood urea nitrogen (BUN) >112 mg/dl or oliguria >72 hours). Of 311 patients, 305 (98.1%) in the early group and 157 of 308 (50.9%) in the delayed group underwent dialysis. Intermittent hemodialysis (IHD) and CKRT were allowed. The 60-day mortalities (primary outcome) were 48.5%, and 49.7% in early and delayed groups, respectively, which were not significantly different (HR, 1.03; 95% CI, 0.81–1.29).
The IDEAL-ICU (Initiation of Dialysis Early versus Delayed in the Intensive Care Unit) study [9] enrolled 488 patients diagnosed with early phase of septic shock (within 48 hours after the start of vasopressor therapy) and AKI from 29 ICUs in France. In the early group, KRT was initiated within 12 hours after documentation of RIFLE (Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease) [10]-failure stage (increase in serum creatinine higher than three times baseline, decrease in urine output to <0.3 ml/kg for ≥24 hours, or anuria sustained for ≥12 hours). In the delayed group, KRT was initiated in the presence of emergent criteria (hyperkalemia >6.5 mmol/L, metabolic acidosis (pH <7.15), or fluid overload). Both IHD and CKRT were allowed, and KRT was implemented in 239 of 246 patients (97%) in the early group and in 149 of 246 patients (62%) in the delayed group. In the delayed group, spontaneous kidney recovery was observed in 70 of 246 patients (29%). At the time of randomization, the median fluid accumulation was 3.2 L/day in both groups. The primary outcome was 90-day mortality, which did not differ significantly between the two groups (early, 58%; delayed, 54%; P=0.38).
The STARRT-AKI (STandard versus Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury) study [11] was the largest randomized RCTs and enrolled 2,927 patients from 168 hospitals in 15 countries. This study aimed to prove the futility of accelerated dialysis in critically ill patients without emergency indications. Among the ICU-admitted patients with KDIGO AKI stage 2 or 3, those with an urgent dialysis indication (serum K >5.5 mmol/L, serum bicarbonate <15 mmol/L), previous KRT within 2 months, kidney transplant recipients, advanced CKD (estimated glomerular filtration rate, <20 mL/min/1.73 m2 at baseline), and uncommon causes of AKI were excluded from the study. The accelerated group received dialysis within 12 hours of documentation, and the standard strategy group received dialysis in case of the development of at least one of the following indications: serum potassium ≥6.0 mmol/L, pH ≤7.2, serum bicarbonate ≤12 mmol/L, FiO2/PaO2 ≤200 and clinical perception of volume overload, or persistent AKI sustained at least 72 hours after randomization. In the accelerated group, 1,418 of 1,462 patients (96.8%) received dialysis, whereas 903 of 1,462 patients (61.8%) in the standard group received dialysis. Both IHD and CKRT were administered. The 90-day mortalities (primary outcome) were 43.9% and 43.7% in the accelerated and standard groups, respectively, which were not significantly different (relative risk [RR], 1.0; 95% CI, 0.93–1.009). Among the 90-day survivors, KRT dependence was significantly higher in the accelerated group than in the standard group (10.4% vs. 6.0%; RR, 1.74; 95% CI, 1.24–2.43).
The AKIKI-2 study [12] was a follow-up study to AKIKI, which aimed to define the safety margins of the delayed strategy. Patients with AKI stage 3 with sustained oliguria for >72 hours or a BUN level >112 mg/dl were included. In the delayed group, dialysis was initiated immediately after randomization. In the more delayed group, KRT was postponed until mandatory indication (hyperkalemia, metabolic acidosis, or pulmonary edema) or BUN >140 mg/dl. A total of 278 patients were enrolled, and the number of KRT-free days on day 28 (primary outcome) were 12 and 10 in the delayed and more delayed groups, respectively (P=0.93). The 60-day mortality rate (secondary outcome) was significantly higher in the more delayed group (55%) than in delayed group (44%) (HR, 1.65; 95% CI, 1.09–2.5).
Detailed inclusion criteria, characteristics, and results of the abovementioned RCTs have been summarized and compared in previous review articles by Bagshaw and Wald [13], An et al. [14], and Bouchard and Mehta [15]. The review article by Bouchard and Mehta [15] is strongly recommended for the further knowledge.
The recent landmark trials showed that in the absence of emergency indications, criteria-based early initiation of KRT was not helpful in improving patient mortality, except in cardiac surgery patients with fluid overload. Meanwhile, too late initiation of KRT would also be harmful. Based on these findings, experts suggested following the STARRT-AKI standard group strategy in decision-making for KRT initiation. Based on the ELAIN study, the early initiation of KRT can be considered in post-cardiac surgery patients with excess fluid accumulation.
Criteria-Based Approach: Challenges
In the previous AKIKI [8] and IDEAL-ICU [9] studies, nearly 40%–50% of patients in the delayed groups did not receive dialysis, and in many cases, AKI spontaneously recovered. In the AKIKI [8] trial, among the 308 patients allocated to the delayed group, 151 (49%) did not receive dialysis. The 60-day mortality rate was the lowest in the delayed group without dialysis (37.1%), followed by the early group (48.5%), and the delayed group with dialysis (61.89%). The Sequential Organ Failure Assessment (SOFA) score at baseline differed among the three groups (delayed group with dialysis >early group >delayed group without dialysis), which implies the need for the development of a prediction tool for KRT requirements based on personalized disease severity rather than strict criteria at a single time point. In the IDEAL-ICU study [9], 93 of 242 patients (49%) in the delayed group did not receive dialysis, and 70 of 93 patients (75.2%) had spontaneous kidney recovery.
The requirement for a personalized approach was tested in a post-hoc analysis of the AKIKI and IDEAL-ICU trials [16]. Based on data from the delayed group, the authors developed a risk prediction model for KRT initiation within 48 hours after allocation, which included serum potassium, BUN, pH, use of non-corticosteroid immunosuppressive drugs, SOFA score, and body weight. A total of 1,107 patients (619 from the AKIKI study and 488 from the IDEAL-ICU study) were re-categorized into quintiles depending on their risks. Compared with delayed treatment, the effects of early initiation varied depending on individual risk levels. Early initiation was harmful in the second quintile (Q2) and highest-risk (Q5) groups and beneficial in the fourth quintile (Q4) group, whereas the timing of dialysis initiation had a neutral effect on mortality in the lowest-risk (Q1) and third quintile (Q3) groups. The heterogeneity of the results revealed challenges in the use of clear-cut criteria based on renal function or AKI stage without considering the clinical context in the decision-making of KRT initiation in critically ill patients.
Personalized Approach Based on the Demand-Capacity Model
The Acute Disease Quality Initiative group suggested a demand and capacity model [17] for dialysis decisions in critically ill patients. The kidneys are assumed to have a finite capacity, and the initiation of KRT should be promoted by the ability of the kidney to meet the demands, including the degree of fluid overload, uremic solutes, chronic comorbidities (diabetes, heart failure, liver cirrhosis, and chronic lung disease), and the degree of disease burden (Figure 2) [18]. As both capacity and demand change over time depending on the course of AKI and critical illness, the gap between demand and capacity changes daily (Figure 3A and B) [18]. Therefore, the decision to initiate KRT must be based on serial assessments of the gap between demand and capacity (Figure 3C and D) [18]. Dialysis must be considered when the demand is expected to exceed the kidney capacity, whereas in the case of a decreasing gap, a watchful waiting strategy can be applied. For instance, in cases of sepsis-induced AKI after a diagnosis of necrotizing pneumonia in patients with baseline CKD and congestive heart failure, KRT could be considered because the patient has a highly demanding condition. The resolution of critical illness takes time; the demand-capacity gap is expected to increase for at least several days, and kidney support would help not lose this patient during the period with the increased gap. In the case of post-renal AKI in which obstruction is already managed, the gap is expected to decrease very soon, and the strategy of watchful waiting would be sufficient.
CKRT is the preferred dialysis method for critically ill patients with hemodynamic instability or acute brain injury [6,19]. However, except for these conditions, recent meta-analysis based on the multiple RCTs showed no survival benefit of CKRT over IHD [20,21]. In AKI survivors, several real-world retrospective studies have shown lower KRT dependence in CKRT users as the initial dialysis method (Table 1) [22-26]. However, criticism regarding the selection bias derived from competing risks (higher mortality rate in the CKRT group associated with greater disease severity) still exists [21]. Nevertheless, several experts argue that CKRT, rather than IHD, is still a promising modality because it allows precise delivery of solutes and fluid removal, safer control of dysnatremia, better control of rhabdomyolysis, and has tangible advantages as a technique of multi-organ support that enables personalized KRT and flexible transition to IHD whenever required [34].
Kidney support [15,35] is different from kidney replacement in patients with end-stage kidney disease. In critically ill patients admitted to the ICU, dialytic intervention can be used not only to remove substances but also to correct electrolyte and acid-base disturbances, achieve fluid balance to facilitate the administration of nutrients or medications, and modulate cytokine levels during inflammatory conditions; it is part of a multi-organ support strategy to mitigate damage related to organ crosstalk. With the concept of the demand-capacity model and “kidney support” in critical illness, non-kidney indications of KRT may exist. Fluid overload in patients with congestive heart failure or acute lung injury in the absence of AKI may be a nonrenal indication for KRT [17].
Recently, hemoadsorption with and without diffusion or convection therapy has been used to provide multi-organ support in patients with sepsis. Early reductions in the levels of interleukin-6 and other inflammatory cytokines have been reported in a few studies; however, little evidence supports the survival benefits of hemoadsorptive therapy (Table 2) [27-33]. Patient selection (who can benefit the most from this technique), proper timing, method, blood flow rate, and duration of hemoadsorption need to be refined. Until sufficient evidence from large RCTs is available, hemoadsorption remains a novel experimental intervention [36,37].
The decision to initiate KRT needs to be personalized, depending on the changes in the demand-capacity balance over time for each patient. Compared to IHD, CKRT has no proven benefit for mortality or kidney recovery; nevertheless, CKRT seems to have tangible benefits as a platform for the multi-organ support technique in critically ill patients.
▪ Emergent dialysis is required in the presence of life-threatening indications, such as medically uncontrolled hyperkalemia, metabolic acidosis, or acute pulmonary edema, whereas non-emergent indications for kidney replacement therapy (KRT) remain unclear.
▪ Results from recent multiple landmark trials discourage early initiation of KRT, based on the acute kidney injury stage at a single time point, and suggest following criteria used in the standard arm of the STARRT-AKI (STandard versus Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury) trial.
▪ A personalized approach based on changes in the demand-capacity gap will facilitate clinical decisions on the initiation of kidney support therapy in critically ill patients.

CONFLICT OF INTEREST

No potential conflict of interest relevant to this article was reported.

FUNDING

This study was supported by a clinical research grant from the Pusan National University Hospital in 2024.

ACKNOWLEDGMENTS

None.

AUTHOR CONTRIBUTIONS

All the work was done by HR.

Figure 1.
Criteria-based dialysis decision in the landmark studies and the introduction of a personalized approach on the decision of dialysis. ELAIN: early versus Late initiation of renal replacement therapy in critically ill patients with acute kidney injury; AKIKI: Artificial Kidney Initiation in Kidney Injury; IDEAL-ICU: Initiation of Dialysis Early versus Delayed in the Intensive Care Unit; STARRT-AKI: STandard versus Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury; KDIGO: Kidney Disease Improving Global Outcomes; ADQI: Acute Dialysis Quality Initiative.
acc-004896f1.jpg
Figure 2.
Conceptual demand-capacity model. Reprinted with permission of Acute Dialysis Quality Initiative (ADQI) [18].
acc-004896f2.jpg
Figure 3.
Four patient scenarios. (A, B) No kidney replacement therapy (KRT)—(A) illustrates early reversal of AKI and (B) shows progressive renal failure and increasing discrepancy between renal function capacity and physiological demands. (C, D) The effect of KRT (dashed lines) with (C) early (line E) or later (line L) initiation and two different demand-capacity discrepancy patterns. On the right, the illustrated patient scenario (D) is different with high underlying disease burden and either initiation of continuous KRT on day 2 transitioning to intermittent KRT on day 4 (dashed line marked as C-I) or initiation of intermittent therapy on day 4 (line I). RRT: renal replacement therapy. Reprinted with permission of Acute Dialysis Quality Initiative (ADQI) [18].
acc-004896f3.jpg
Table 1.
Influence initial dialysis modality on the long-term outcomes in critically ill patients with AKI
Study Setting Population Inclusion Outcome Results
Incidence Risk estimation
Koyner et al. (2024) [22] Retrospective, U.S. claim data 3,804 - KRT dependence at discharge and 90 days At discharge: CKRT, 26.5%; IHD, 29.8% Lower in CKRT (OR, 0.68; 95% CI, 0.47–0.97)
At 90 days: CKRT, 4.9%; IHD, 7.4%
Wald et al. (2023) [23] Multicenter (168), muti-nations (15) CKRT, 1,590; IHD, 606 Secondary analysis of STARRT-AKI Death or KRT dependence at 90 days CKRT, 51.8%; IHD, 54.3% Lower in CKRT (OR, 0.84; 95% CI, 0.66–0.99)
Bonnassieux et al. (2018) [24] Retrospective cohort study in 291 ICUs in France 24,750 - Kidney recovery (dialysis free) at discharge - Lower in IHD (OR, 0.910; 95% CI, 0.834–0.992)
Truche et al. (2016) [25] Prospective multicenter study in France 1,360 OUTCOMERE database 30-Day mortality and KRT dependence - No difference (HR, 1.00; 95% CI, 0.77–1.29)
KRT dependence alone
Lower in CKRT (HR, 0.54; 95% CI, 0.29–0.99)
Wald et al. (2014) [26] Retrospective cohort study in Canada CKRT, 2004; IHD, 2004 - KRT dependence (median FU 3 years) - Lower in CKRT (HR, 0.75; 95% CI, 0.65–0.87)

AKI: acute kidney injury; KRT: kidney replacement therapy; CKRT: continuous kidney replacement therapy; IHD: intermittent hemodialysis; OR: odds ratio; STARRT-AKI: STandard versus Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury; ICU: intensive care unit; HR: hazard ratio.

Table 2.
Recent randomized controlled studies on hemoadsorption therapy
Study Setting Population Inclusion Hemoadsorption Primary outcome Secondary outcome Other significance
Diab et al. (2022) [27] 14 Centers in Germany 288 Cardiac surgery for IE CytoSorb ΔSOFA: no difference 30-Day mortality: 21% vs. 22%, P=0.782 -
Feng et al. (2022) [28] Single center in China 16 Surgical septic shock with AKI Oxiris ↓PCT, IL-6: decreased in Oxiris; ↓Lactate: decreased in Oxiris -
Norepinephrine reduced in Oxiris
Broman et al. (2019) [29] Single center in Sweden 16 Septic shock-associated AKI and with high endotoxin level Oxiris ↓Endotoxin: 77.8% vs. 16.7%, P=0.02; ↓Cytokine level: better in Oxiris Treatment effect was significant only in the
Norepinephrine reduction in Oxiris 0–24 hours of treatment and not in 24-48 hours.
Hawchar et al. (2019) [30] Pilot study in Hungary 20 Septic shock on vent without need for KRT CytoSorb ΔSOFA: no difference; hemodynamic changes: no difference -
Dellinger et al. (2018) [31] 55 Centers in the United States, Canada 450 Septic shock and endotoxin ≥0.6 Polymyxin B 28-Day mortality: no difference - -
Schädler et al. (2017) [32] 10 Centers in Germany 97 Septic shock and ALI or ARDS CytoSorb Normalization of IL-6: no difference Ventilator time: no difference; normalization of other cytokines: no difference; 60-day mortality: no difference -
Cruz et al. (2009) [33] 10 Centers in Italy 64 Severe sepsis or septic shock Polymyxin B ΔMAP and vasopressor requirement: better in polymyxin B group ΔPaO2/FiO2: better in polymyxin B; ΔSOFA: better in polymyxin B; ↓28-day mortality: decreased in polymyxin B -

IE: infective endocarditis; SOFA: Sequential Organ Failure Assessment; AKI: acute kidney injury; PCT: procalcitonin; IL-6: interleukin 6; KRT: kidney replacement therapy; ALI: acute lung injury; ARDS: acute respiratory distress syndrome; ΔMAP: delta mean arterial pressure.

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        Dialysis decision in critically ill patients in intensive care unit
        Acute Crit Care. 2025;40(1):1-9.   Published online February 28, 2025
        DOI: https://doi.org/10.4266/acc.004896
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      Dialysis decision in critically ill patients in intensive care unit
      Image Image Image
      Figure 1. Criteria-based dialysis decision in the landmark studies and the introduction of a personalized approach on the decision of dialysis. ELAIN: early versus Late initiation of renal replacement therapy in critically ill patients with acute kidney injury; AKIKI: Artificial Kidney Initiation in Kidney Injury; IDEAL-ICU: Initiation of Dialysis Early versus Delayed in the Intensive Care Unit; STARRT-AKI: STandard versus Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury; KDIGO: Kidney Disease Improving Global Outcomes; ADQI: Acute Dialysis Quality Initiative.
      Figure 2. Conceptual demand-capacity model. Reprinted with permission of Acute Dialysis Quality Initiative (ADQI) [18].
      Figure 3. Four patient scenarios. (A, B) No kidney replacement therapy (KRT)—(A) illustrates early reversal of AKI and (B) shows progressive renal failure and increasing discrepancy between renal function capacity and physiological demands. (C, D) The effect of KRT (dashed lines) with (C) early (line E) or later (line L) initiation and two different demand-capacity discrepancy patterns. On the right, the illustrated patient scenario (D) is different with high underlying disease burden and either initiation of continuous KRT on day 2 transitioning to intermittent KRT on day 4 (dashed line marked as C-I) or initiation of intermittent therapy on day 4 (line I). RRT: renal replacement therapy. Reprinted with permission of Acute Dialysis Quality Initiative (ADQI) [18].

      Figure 1.

      Figure 2.

      Figure 3.

      Dialysis decision in critically ill patients in intensive care unit
      Study Setting Population Inclusion Outcome Results
      Incidence Risk estimation
      Koyner et al. (2024) [22] Retrospective, U.S. claim data 3,804 - KRT dependence at discharge and 90 days At discharge: CKRT, 26.5%; IHD, 29.8% Lower in CKRT (OR, 0.68; 95% CI, 0.47–0.97)
      At 90 days: CKRT, 4.9%; IHD, 7.4%
      Wald et al. (2023) [23] Multicenter (168), muti-nations (15) CKRT, 1,590; IHD, 606 Secondary analysis of STARRT-AKI Death or KRT dependence at 90 days CKRT, 51.8%; IHD, 54.3% Lower in CKRT (OR, 0.84; 95% CI, 0.66–0.99)
      Bonnassieux et al. (2018) [24] Retrospective cohort study in 291 ICUs in France 24,750 - Kidney recovery (dialysis free) at discharge - Lower in IHD (OR, 0.910; 95% CI, 0.834–0.992)
      Truche et al. (2016) [25] Prospective multicenter study in France 1,360 OUTCOMERE database 30-Day mortality and KRT dependence - No difference (HR, 1.00; 95% CI, 0.77–1.29)
      KRT dependence alone
      Lower in CKRT (HR, 0.54; 95% CI, 0.29–0.99)
      Wald et al. (2014) [26] Retrospective cohort study in Canada CKRT, 2004; IHD, 2004 - KRT dependence (median FU 3 years) - Lower in CKRT (HR, 0.75; 95% CI, 0.65–0.87)
      Study Setting Population Inclusion Hemoadsorption Primary outcome Secondary outcome Other significance
      Diab et al. (2022) [27] 14 Centers in Germany 288 Cardiac surgery for IE CytoSorb ΔSOFA: no difference 30-Day mortality: 21% vs. 22%, P=0.782 -
      Feng et al. (2022) [28] Single center in China 16 Surgical septic shock with AKI Oxiris ↓PCT, IL-6: decreased in Oxiris; ↓Lactate: decreased in Oxiris -
      Norepinephrine reduced in Oxiris
      Broman et al. (2019) [29] Single center in Sweden 16 Septic shock-associated AKI and with high endotoxin level Oxiris ↓Endotoxin: 77.8% vs. 16.7%, P=0.02; ↓Cytokine level: better in Oxiris Treatment effect was significant only in the
      Norepinephrine reduction in Oxiris 0–24 hours of treatment and not in 24-48 hours.
      Hawchar et al. (2019) [30] Pilot study in Hungary 20 Septic shock on vent without need for KRT CytoSorb ΔSOFA: no difference; hemodynamic changes: no difference -
      Dellinger et al. (2018) [31] 55 Centers in the United States, Canada 450 Septic shock and endotoxin ≥0.6 Polymyxin B 28-Day mortality: no difference - -
      Schädler et al. (2017) [32] 10 Centers in Germany 97 Septic shock and ALI or ARDS CytoSorb Normalization of IL-6: no difference Ventilator time: no difference; normalization of other cytokines: no difference; 60-day mortality: no difference -
      Cruz et al. (2009) [33] 10 Centers in Italy 64 Severe sepsis or septic shock Polymyxin B ΔMAP and vasopressor requirement: better in polymyxin B group ΔPaO2/FiO2: better in polymyxin B; ΔSOFA: better in polymyxin B; ↓28-day mortality: decreased in polymyxin B -
      Table 1. Influence initial dialysis modality on the long-term outcomes in critically ill patients with AKI

      AKI: acute kidney injury; KRT: kidney replacement therapy; CKRT: continuous kidney replacement therapy; IHD: intermittent hemodialysis; OR: odds ratio; STARRT-AKI: STandard versus Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury; ICU: intensive care unit; HR: hazard ratio.

      Table 2. Recent randomized controlled studies on hemoadsorption therapy

      IE: infective endocarditis; SOFA: Sequential Organ Failure Assessment; AKI: acute kidney injury; PCT: procalcitonin; IL-6: interleukin 6; KRT: kidney replacement therapy; ALI: acute lung injury; ARDS: acute respiratory distress syndrome; ΔMAP: delta mean arterial pressure.

      Table 1.

      Table 2.

      ACC : Acute and Critical Care
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