Acute kidney injury (AKI) is a common and severe complication in the intensive care unit (ICU). Due to its high incidence, strong correlation with poor prognosis, and substantial consumption of medical resources, AKI has become one of the central challenges in modern critical care medicine. Epidemiological studies worldwide indicate that up to 50–60% of ICU patients experience varying degrees of AKI, with approximately 10–15% progressing to severe stages requiring renal replacement therapy (RRT).
Renal replacement therapy (RRT) is a vital life-support modality for critically ill patients with AKI. However, there is still no universally accepted standard regarding treatment protocols and when to initiate or discontinue RRT.
Explaining the urgent need for a consensus guideline, Prof. Chen, the lead author, shares, "RRT in critically ill patients occurs within a dynamic, variable, and often hemodynamically unstable physiological environment, necessitating highly individualized and flexible RRT strategies." Prof. Chen adds, "Although RRT techniques have been used clinically for decades, there remains a lack of unified clinical standards for core issues including the timing of RRT initiation, treatment modality, anticoagulation strategy, and weaning from RRT." The clinical practice guideline was made available online on August 18, 2026, in the Journal of Intensive Medicine.
The Chinese Society of Critical Care Medicine organized a multidisciplinary expert panel to develop the clinical practice guideline for RRT in accordance with the GRADE approach for grading evidence quality. The authors developed the guideline through systematic literature retrieval, meta-analysis, and evidence-based medical evidence synthesis.
The authors listed three commonly used AKI diagnosis and classification systems, namely, risk, injury, failure, loss, ESRD (RIFLE) criteria; Risk, Injury, Failure, Loss of Kidney Function, and End-stage Kidney Disease criteria developed by the Acute Kidney Injury Network (AKIN); and the Kidney Disease: Improving Global Outcomes (KDIGO) guidelines. In the guideline, they put forward a total of 34 recommendations across seven domains, organized around 29 clinical questions. They covered key clinical topics including timing of RRT initiation, establishment and maintenance of vascular access, selection of treatment modalities, application of specialized membrane filters, anticoagulation regimens, replacement fluid formulations, prescribed treatment dose, and RRT weaning strategies. The recommendations are applicable only to adult critically ill patients.
The recommendations were categorized as strong or weak based on the GRADE methodology. During the establishment of RRT vascular access ultrasound evaluation, localization, and real-time ultrasound-guided puncture are strongly recommended. Regarding anticoagulation regimen selection for continuous renal replacement therapy (CRRT), for patients without bleeding risk, regional citrate anticoagulation (RCA) is strongly recommended as the first-line anticoagulation strategy for CRRT. For patients without bleeding risk but with a risk of citrate accumulation, heparin anticoagulation is strongly recommended as the first-line strategy for CRRT. For patients with bleeding risk, RCA is strongly recommended as the first-line strategy.
The guidelines recommend RRT initiation as early as possible in AKI patients presenting with life-threatening fluid overload, electrolyte disturbances, or acid-base imbalances. RRT should not be delayed in AKI patients with blood urea nitrogen levels over 40 millimolars per liter or clinical manifestations of uremic encephalopathy. As per the recommendations, the catheterization site for RRT catheters can be the right internal jugular vein or femoral vein.
The guideline recommends that for patients with AKI, either continuous RRT or intermittent RRT may be selected based on the patient's clinical condition and treatment goals. Furthermore, regarding trial discontinuation of RRT, recovery of urine output to over 600 mL in 24 h on the day prior, or to over 1000 mL in 24 h on the day of liberation, is suggested as reference criteria.
Stressing the significance of having a consensus practice guideline, Prof. Chen says, "Through this guideline, we aim to provide scientific, standardized, and clinically actionable guidance for critical care practitioners in China, promoting standardized RRT management in adult critically ill patients with AKI."
In summary, the 2026 clinical practice guidelines are a valuable reference for clinicians considering RRT in critically ill adult patients with life-threatening acute kidney injury, and is expected to effectively reduce the incidence of AKI-related morbidity and mortality.
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