Integration of continuous renal replacement therapy in patients on extracorporeal life support - timing, modality, and future directions

Sep 30, 2026

Editorial discussing integration of continuous renal replacement therapy (RRT) for critically ill cardiovascular patients receiving extracorporeal life support, focusing on timing and modality. Highlights include high incidence of acute kidney injury (AKI) and wide RRT use across ECMO and cardiogenic shock, with consistently worse outcomes. Argues universal early initiation is not clearly beneficial because ICU trial data under-represent these populations, so syndrome- and device-specific thresholds are needed. Notes ECMO-device bidirectional interactions and the role of patient selection and periprocedural management, proposing early nephrology involvement and protocolized strategies.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages4

Reading Time10 min

AccessFree to download

Editorial

Background and rationale

Epidemiology and prognostic implications

Limitations of extrapolating general ICU trial data

ECMO-associated bidirectional device–kidney interactions

Modality and practical integration

Renal FailuRe 2025, VOl. 47, nO. 1, 2604452 [https://doi.org/10.1080/0886022X.2025.2604452](https://doi.org/10.1080/0886022X.2025.2604452) Editorial Integration of continuous renal replacement therapy in patients on extracorporeal life support: timing, modality, and future directions Jian Houa*, Zhuandi linb*, Jianhao lia, dayu Wanga, Bo Huc and Guangtao Xuc aDepartment of Cardiology, Cardiovascular Research institute, the affiliated Panyu Central Hospital, Guangzhou Medical university, Guangzhou, Guangdong, China; bintensive Care unit, the affiliated Panyu Central Hospital, Guangzhou Medical university, Guangzhou, Guangdong, China; cDepartment of Pathology, institute of Forensic Science, College of Medicine, Jiaxing university, Jiaxing, Zhejiang, China ARTICLE HISTORY received 28 october 2025; revised 1 december 2025; accepted 9 december 2025 acute kidney injury (aKi) and the need for renal replacement therapy (rrt) remain pervasive complications among critically ill cardiovascular patients [1–3] . Current investigations illuminate several interlinked key points that should guide clinical practice and research priorities, including the following aspects: (1) cardiorenal interactions in critical cardiovascular disease and extracorporeal support are common and prognostically important; (2) optimal timing, modality, and integration of rrt with other extracorporeal technologies remain unresolved and likely require syndrome- and device-specific approaches; and (3) future progress needs pragmatic trials and mechanistic studies that account for device-organ crosstalk and patient-centered outcomes. First, the epidemiology and prognostic implications of acute kidney injury/renal replacement therapy (aKi/rrt) in cardiovascular critical care are stark [4] . large registry- and cohort-derived data reviewed show aKi incidence of roughly 30–85% depending on the population and definition, and rrt utilization that varies widely (a few percent to >50%) in extra-corporeal membrane oxygenation (ECMo) and cardiogenic shock cohorts [5,6] . importantly, both critical cardiovascular disease and those receiving temporary mechanical circulatory support face substantially higher risks of aKi and rrt and, correspondingly, higher short-term mortality [7,8] . the Canadian review on rrt in cardiogenic shock summarized these points and emphasized that rrt in this context is associated with markedly worse outcomes—a consistent finding across the collection [9] . Second, the limitations of extrapolating general iCU rrt trial data to cardiovascular populations might exist. randomized timing trials in heterogeneous critically ill cohorts (ElaiN, aKi Ki, Starrt-aKi and related trials) have not demonstrated clear survival benefits for early universal initiation of rrt and in some cases signaled harm (infections, dialysis-dependence) [10] . these trials largely under-represent critical cardiovascular disease and ECMo patients, whose hemodynamic vulnerabilities and susceptibility to volume-related organ interactions differ fundamentally from septic or postoperative cohorts [11] . thus, the ‘one-size-fits-all’ timing paradigm is unlikely to be optimal for cardiovascular extracorporeal settings. the review authors therefore reasonably propose tailored thresholds-for example, a lower pH threshold and explicit consideration of diuretic-resistance and venous congestion as indications for rrt in cardiogenic shock - while acknowledging that prospective data are lacking [9] . these individualized thresholds reflect the unique physiology of cardiogenic shock, in which severe venous congestion, impaired renal perfusion, and metabolic acidosis progress differently compared with sepsis or postoperative states. lower pH thresholds, refractory diuretic resistance, and clinical evidence of venous hypertension are therefore used as early surrogates of impending organ injury in this population. third, papers analyzing ECMo-associated aKi reinforce the bi

FAQs

Why is AKI and RRT especially important in cardiovascular critical care?

AKI and the need for RRT are pervasive complications in critically ill cardiovascular patients, with higher risks and higher short-term mortality in those receiving temporary mechanical circulatory support.

What is the key problem with applying general ICU RRT timing trial results to cardiovascular populations?

Randomized timing trials in heterogeneous ICU cohorts have not shown clear survival benefits for early universal initiation, and the evidence may be limited because critical cardiovascular and ECMO patients are under-represented and have different hemodynamic vulnerabilities.

How should timing and indications for RRT be approached in cardiogenic shock?

The article suggests tailored thresholds using syndrome-specific physiology, such as considering lower pH thresholds and explicit attention to diuretic resistance and venous congestion, while noting prospective data remain lacking.

Sep 30, 2026

Uploaded by Alexandar