The Case for CRRT Is Growing.
So Is the Need for Skilled Delivery.

Fifteen or twenty years ago, continuous renal replacement therapy (CRRT) was often seen as a last-resort intervention. It was largely thought of as something done for critically ill patients and their families that did little more than delay the inevitable. At the time, acute kidney injury (AKI) care had stalled. We'd made little progress in reducing the stubbornly high rates of mortality and morbidity.

But that is now changing. In my personal experience and conversations with colleagues in the field, CRRT is increasingly recognized as a potentially life-saving intervention. There's a growing body of evidence showing it can improve patient outcomes, including renal recovery.^1–3 It may even be superior to intermittent hemodialysis (IHD) in certain circumstances.^1,2 

Javier Neyra and colleagues’ new study,⁴ published in Intensive Care Medicine, adds further weight to the argument for CRRT. Neyra and colleagues looked at data from around 50,000 critically ill ICU patients receiving RRT in 426 hospitals across the US. Their findings suggest that hospitals with higher CRRT volumes – those who did CRRT more frequently – had better patient outcomes. The mortality benefit could be as high as 15%, which is huge in a field where improvements have been elusive and hard-fought.

Still, most of this evidence is retrospective. Prospective, randomized trials are needed to confirm these promising trends.

What’s clear from the evidence so far is the need to prioritize quality improvement and the expansion of well-managed CRRT programs. Unlike outpatient dialysis, CRRT has lacked standardized metrics and quality controls, making quality initiatives an important next step.

The data also point to the importance of expertise. CRRT isn’t a machine you can wheel in occasionally. Hospitals that rely on it just a few times a month are unlikely to get the same outcomes as centers using it more often than that. It demands continuous oversight and skilled management. 

Effective CRRT starts with thoughtful patient selection and is further boosted by good management. That means keeping filters running smoothly, minimizing complications, and establishing protocols in place for early detection and intervention.

Achieving this level of care requires a coordinated, multidisciplinary team that includes nephrologists, intensivists, dialysis and ICU nurses, and dialysis technicians, who are working together with shared ownership of the process.

While smaller hospitals may face resource constraints, Neyra and colleagues’ data are strong enough to justify serious consideration for establishing a CRRT program – even in mid-sized centers where they don’t yet exist. The cost is relatively modest compared with the potential to save lives and improve post-AKI renal recovery. These hospitals could look to larger, more experienced institutions for guidance.

Of course, more research is needed, especially around identifying the right patients for CRRT. It’s not about applying the therapy universally, but about refining treatment timing, patient selection, and care delivery including the possibility of starting CRRT slightly earlier than is typically done today to avoid fluid overload.

Ultimately, these data are a starting point. By optimizing existing tools like CRRT and building on current evidence, even small percentage gains in outcomes could add up to meaningful progress in the care of critically ill patients.