Optimizing a Dose Prescription as the First Step of Green Continuous Kidney Replacement Therapy

Rationale & Objective

Continuous kidney replacement therapy (CKRT) requires a large amount of fluid; however, it is often overused in clinical settings, leading to fluid waste. This study aimed to investigate the influence of dose optimization on fluid consumption and dialysis efficacy.

Study Design

Single-center prospective study.

Setting & Participants

All patients treated with CKRT at Pusan National University Hospital between May 1 and December 31, 2023.

Quality Improvement Activities

The CKRT prescription dose was adjusted from the previous 35-25-30 mL/kg/h, targeting delivered doses between 20 and 25 mL/kg/h, as per the Kidney Disease: Improving Global Outcomes recommendations.

Outcomes

The primary outcome was the change in total fluid consumption, and the secondary outcome was the differences in the pattern of biochemical parameter changes after 48 hours of CKRT before and after the study (serum urea nitrogen, creatinine, potassium, phosphate, and bicarbonate).

Analytic Approach

General linear model for the primary outcome; repeated measures analysis of variance for the secondary outcome.

Results

A total of 441 patients were included before (N = 210) and after (N = 231) participating in the study. The median age was 70.0 (61.0-77.5) years; 67.3% were male, and 17.6% had end-stage kidney disease. Before the study, the median prescribed dose for CKRT was 34.1 (33.0-35.4) mL/kg/h, with the median amount of fluid consumption being 53.6 (43.0-63.2) L/person/d. During the study periods, the median delivered dose was reduced to 27.4 mL/kg/h (P < 0.001), and total fluid consumption was reduced by 6.7 (3.7-9.8) L/person/d, with a median reduction in plastic package usage of 1.3 (0.8-1.9) (P < 0.001). The degree of biochemical changes was not significantly different before and after the study.

Limitations

The fluid-saving effect may be greater in countries with heavier patients.

Conclusions

Efforts to optimize CKRT dosing allowed for a 12.7% reduction in fluid consumption (ie, 6.7 L/person/d), without any additional changes in treatment efficacy.

Plain Language Summary

Greening of intensive care is essential; however, it is often challenging in critically ill patients, because the greening process should not compromise patient safety. Continuous kidney replacement therapy is the most common method of dialysis in the intensive care unit, requiring large amounts of fluid. This quality improvement study controlled the delivered dialysis dose by reducing treatment intensity and analyzed its impact on fluid savings and treatment efficacy. Reducing the dose prescription by 3.3 mL/kg/h resulted in savings of approximately 6.7 L of fluid and 1.3 dialysate packages per person per day, without compromising dialysis efficacy. Although these are small changes at the individual patient level, their impact on the environment would be substantial if similar fluid-saving strategies were adopted in centers worldwide.