Liberation from continuous renal replacement therapy due to renal recovery in adults and children: a literature review and Delphi consensus on clinical practice
Bibliographic record
Abstract
There is no current consensus on the appropriate timing for discontinuing continuous renal replacement therapy (CRRT). We aimed to review the current clinical evidence associated with the successful liberation from CRRT in patients with acute kidney injury and present a literature review with clinical practice points using a modified Delphi process. EMBASE, CINAHL, PubMed, and CENTRAL libraries were searched for literature related to CRRT liberation in pediatric and adult AKI patients. A two-round modified Delphi process was conducted to establish clinical and research practice points for successful liberation from CRRT in adults and children. Statements with over 75% of respondents rating them at least a 3 on a 5-point Likert scale were classified as clinically relevant practice points. Statements requiring more data were labeled as future research recommendations. Out of 1,380 articles procured, 18 studies met the eligibility criteria: ten studies on adult CRRT liberation (n = 3,357 patients) and eight on pediatric CRRT liberation (n = 939 patients). Demographic, clinical, and laboratory information were abstracted from the medical records. Four pediatric and five adult studies mentioned urine output (UOP). In adults, a 2-hour creatinine clearance above 23 mL/min was found to be a strong predictor of successful CRRT liberation, with UOP thresholds of > 60 mL/hr or > 400 mL/day correlating with successful outcomes. In pediatric patients, UOP > 0.5 mL/kg/hr within 6 h before liberation appeared to be a reliable predictor. A pooled analysis was unable to be conducted due to the limited number of studies, variations in study design, significant heterogeneity of patient populations, absence of prospective and external validation, and the lack of a standardized definition for CRRT liberation. UOP without the use of diuretics prior to liberation from CRRT was the most commonly reported predictor for successful CRRT liberation. In addition to urine output, urinary creatinine excretion, creatinine clearance, and fluid balance may be considered as potential predictive parameters when liberating from CRRT. Current recommendations emphasize the need for an individualized approach to CRRT liberation. Additional prospective studies are needed to strengthen these recommendations, focusing on the determination of UOP thresholds and validating additional clinical and biochemical parameters or risk-classification models. Our study focuses on identifying predictors for continuous renal replacement therapy (CRRT) liberation in patients recovering from acute kidney injury in both adults and children. We conducted a literature review for studies regarding discontinuing CRRT in adults and children. We used a panel of experts to establish clinical practice points that could improve patient outcomes by optimizing CRRT liberation decisions. We present practice points for various potential indicators for CRRT liberation, including urine output, serum and urinary creatinine, creatinine clearance, and fluid balance. We recommend further research to support individualized CRRT liberation decisions, which remain largely based on clinical judgment.
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How this classification was reachedexpand
Full frame machine prediction
Teacher imitationNot calibrated prevalence, not ground truth. Human validation pending. The Gemma side is a direct model label for every work in the frame, read from the title-only record. The Codex side is a classifier learned from the 10,348 direct Codex labels and calibrated to design-weighted sample rates; fields without enough sample support carry no Codex call. Candidate is the union of the two sides; consensus is their intersection. These outputs are machine_predicted_unvalidated and are not human labels.
Distilled classifier scores by category (both heads)
| Category | Codex | Gemma |
|---|---|---|
| Metaresearch | 0.162 | 0.195 |
| Meta-epidemiology (narrow) | 0.001 | 0.001 |
| Meta-epidemiology (broad) | 0.003 | 0.004 |
| Bibliometrics | 0.021 | 0.013 |
| Science and technology studies | 0.003 | 0.006 |
| Scholarly communication | 0.006 | 0.009 |
| Open science | 0.002 | 0.008 |
| Research integrity | 0.004 | 0.003 |
| Insufficient payload (model declined to judge) | 0.003 | 0.000 |
Machine scores (provisional)
The two teacher heads of the student model, read on this work. A score orders the frame for review; it never asserts a category, and the validation status ships verbatim with every row.
Baseline scores from an immature model (maturity gate not passed, 7 training rounds). Scores rank; they never assert a category.
score_only:v0-immature-baseline · verbatim from the scoring run: score_only means the number may rank works, and no category label ships from itClassification
machine, unvalidatedMachine predicted; a candidate call from one source (direct Gemma or distilled Codex), not a consensus.
How this classification was reached, model by model and score by score, is at the end of the page under "How this classification was reached".