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With no trial evidence guiding de-escalation in the ICU for survivors of severe AKI, the review explains how to move from CRRT to intermittent RRT modalities. It addresses complications during transition, including failure to transition and intradialytic hypotension, and their links to mortality and delayed kidney recovery. Key attention is given to modality choice, volume status–guided strategy, and medication dosing, especially antimicrobials, throughout this vulnerable period.",{"@graph":69,"@context":123},[70,84,106],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/proceedings-of-the-university-of-alabama-at-birmingham-continuous-renal-replacement-therapy-academy-20232024-managing-de-escalation-of-acute-renal-replacement-therapy-and-optimizing-drug-dosing-during-renal-replacement-therapy-transitions/452651/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/proceedings-of-the-university-of-alabama-at-birmingham-continuous-renal-replacement-therapy-academy-20232024-managing-de-escalation-of-acute-renal-replacement-therapy-and-optimizing-drug-dosing-during-renal-replacement-therapy-transitions/452651.png","ImageObject",300,407,{"name":92,"@type":93},"LangkahRina","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-06","2026-09-30",true,{"@type":102,"interactionType":103,"userInteractionCount":105},"InteractionCounter",{"@type":104},"ViewAction",14,{"@type":107,"mainEntity":108},"FAQPage",[109,115,119],{"name":110,"@type":111,"acceptedAnswer":112},"Why is de-escalation from CRRT to intermittent RRT challenging in the ICU?","Question",{"text":113,"@type":114},"There is no trial data to guide RRT de-escalation in critically ill patients. Transition periods can cause complications such as failure to transition and intradialytic hypotension, which are associated with higher mortality and reduced odds of kidney recovery.","Answer",{"name":116,"@type":111,"acceptedAnswer":117},"What factors does the review emphasize when managing RRT de-escalation?",{"text":118,"@type":114},"It focuses on modality transition decisions, the role of volume status in guiding the approach, and careful drug dosing—particularly antimicrobial agents—during the transition period.",{"name":120,"@type":111,"acceptedAnswer":121},"What went wrong in the presented case during attempts to discontinue CRRT?",{"text":122,"@type":114},"After CRRT discontinuation with planned intermittent hemodialysis, the patient developed atrial fibrillation and hypotension, requiring immediate stopping of IHD, fluid resuscitation, cardioversion, and reintubation, followed by CRRT reinitiation. 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Pedro Teixeira  ,3 Jorge Cerda  ,4 Michael J. Connor Jr.  ,5 Amanda Dijanic Zeidman  ,6 Pranav S. Garimella  ,7 Luis Juncos  ,8 Arnaldo Lopez-Ruiz  ,9 Ravindra Mehta  , 10 Thiago Reis  , 11 Lilia Rizo-Topete  , 12 Samuel A. Silver , 13 J. Ricardo Da Silva  , 14 Rajesh Speer  , 15 Anitha Vijayan  , 16 Catherine Wells  , 17 Keith Wille  , 18 Lenar Yessayan  , 19 Ashita Tolwani  , 15 and Javier A. Neyra  15  \nIn this second installment of the proceedings of the University of Alabama at Birmingham Continuous Renal Replacement Therapy (CRRT) Academy, we focus on the topic of transitions of care in acute renal replacement therapy (RRT). Although we have accumulated data from thousands of critically ill patients with AKI randomized to different strategies for RRT initiation, no trial data exist to guide de-escalation of RRT in the intensive care unit. However, for survivors of severe AKI whose kidney function does not recovery rapidly enough to allow for liberation directly from CRRT, successful deescalation of care requires the transition from CRRT to intermittent RRT modalities. These transition periods must be carefully navigated since they can be a source of complications, such as failure to transition or intradialytic hypotension, which are in turn associated with an increased risk of mortality and reduced odds of kidney recovery. In this review, we focus on the critical factors to consider during de-escalation of RRT care, with a focus on modality transition, the role of volume status in guiding the approach to de-escalation of RRT, and the vital importance of careful dosing of drugs, especially antimicrobial agents, during this transitional period.  \nKidney360 6: 1798–1809, 2025. doi: [https://doi.org/10.34067/KID.0000000951](https://doi.org/10.34067/KID.0000000951)  \nIntroduction  \nThe University of Alabama at Birmingham Continuous Renal Replacement Therapy (CRRT) Academy is a 2-day conference hosted annually in the fall dedicated to the education of health care professionals on key aspects of CRRT. For the past 3 years, the meeting has also been expanded to include the review of recent developments in the field of critical care nephrology through the introduction of keynote speakers and plenary sessions.1  \nIn this second installment of the proceedings of the University of Alabama at Birmingham CRRT Academy, we aim to summarize and disseminate the insights provided by the faculty on the topic of caring for patients with severe AKI requiring renal replacement therapy (RRT) who survived the initial period of critical illness. We will more specifically explore the topic of RRT de-escalation in the  \nintensive care unit (ICU), focusing on modality transitionsand considerations regarding medication dosing in this setting.  \nCase Example: An “Unsuccessful” Case of RRT De-Escalation  \nA 65-year-old man is admitted to the ICU after mitral valve replacement and coronary artery bypass surgery which subsequently required urgent pericardial drainage for tamponade. He has preexisting stage 3 CKD and apremorbid weight of 85 kg. The first week after surgery is complicated by mixed cardiogenic and vasoplegic shock requiring high-dose vasopressor and ionotropic support. CRRT is initiated on postoperative day 2 for severe AKI with oliguria.  \nDue to the number of contributing authors, the affiliations are listed at the end of this article.  \nCorrespondence: Dr. Javier A. Neyra, [email:](email: jneyra@uabmc.edu)[ jneyra@uabmc.edu](email: jneyra@uabmc.edu)[ ](email: jneyra@uabmc.edu)[Published Online Ahead of Print:](Published Online Ahead of Print: August 8)[ August 8](Published Online Ahead of Print: August 8), 2025  \nW.B.-S. ","cbCaicqSIUp9nVoZ","https://ap.wps.com/l/cbCaicqSIUp9nVoZ","pdf",994097,12,"English","# Introduction\n## Case Example: An “Unsuccessful” Case of RRT De-Escalation\n## RRT-Induced Organ Injury","[{\"question\":\"Why is de-escalation from CRRT to intermittent RRT challenging in the ICU?\",\"answer\":\"There is no trial data to guide RRT de-escalation in critically ill patients. Transition periods can cause complications such as failure to transition and intradialytic hypotension, which are associated with higher mortality and reduced odds of kidney recovery.\"},{\"question\":\"What factors does the review emphasize when managing RRT de-escalation?\",\"answer\":\"It focuses on modality transition decisions, the role of volume status in guiding the approach, and careful drug dosing—particularly antimicrobial agents—during the transition period.\"},{\"question\":\"What went wrong in the presented case during attempts to discontinue CRRT?\",\"answer\":\"After CRRT discontinuation with planned intermittent hemodialysis, the patient developed atrial fibrillation and hypotension, requiring immediate stopping of IHD, fluid resuscitation, cardioversion, and reintubation, followed by CRRT reinitiation. Later, even with increased IHD frequency, intradialytic hypotension recurred.\"}]","Proceedings of the University of Alabama at Birmingham Continuous Renal Replacement Therapy Academy (2023–2024) - Managing De-Escalation of Acute Renal Replacement Therapy and Optimizing Drug Dosing during Renal Replacement Therapy Transitions | PDF",1790737530]