Renal Replacement Therapy in the ICU: Modality Choice, Dose Optimization, and Resource Disparities Across Regions

Acute kidney injury is one of the most common complications in the intensive care unit, and a substantial proportion of affected patients require renal replacement therapy (RRT). Clinicians can choose between continuous renal replacement therapy (CRRT), intermittent hemodialysis (IHD), and hybrid approaches such as sustained low-efficiency dialysis (SLED) or prolonged intermittent RRT (PIRRT). Although major trials have shown broadly comparable outcomes between modalities and no survival benefit from higher-intensity dosing, real-world practice remains highly variable. Decisions about modality, timing, dose, and weaning are often shaped as much by local cost, available equipment, and staff expertise as by physiology. These differences are especially pronounced between high- and lower-resource settings, where access to RRT and to trained personnel can differ considerably.

This Research Topic aims to examine how RRT modality and dose are chosen across different clinical and regional settings, and to identify resource-conscious strategies that preserve patient outcomes while reducing cost and treatment-related harm. Despite international guidelines, wide variation persists in how acute RRT is prescribed, delivered, de-escalated, and discontinued. This Topic seeks to bring together clinical, economic, and educational perspectives to clarify which practices add value and which contribute to avoidable burden, including the iatrogenic complications sometimes described as “dialytrauma.” A particular aim is to surface data from under-represented regions, including Latin America, so that recommendations reflect the realities of diverse healthcare systems. By combining original data, surveys, and expert synthesis, the collection intends to support more rational, equitable, and sustainable RRT delivery in the critically ill.

We welcome contributions addressing, but not limited to:

- Comparative outcomes of CRRT, intermittent hemodialysis, and hybrid modalities (SLED/PIRRT)

- Dose optimization and de-escalation of RRT intensity

- Timing of initiation, weaning, and discontinuation of RRT

- Cost, resource use, and the economic or environmental burden of dialysis

- Regional and international surveys of practice, access, and training

- Strategies to prevent treatment-related harm (“dialytrauma”)

- Education, simulation, and rational prescribing in critical care nephrology

We welcome the following article types: Original Research, Review, Mini-Review, Systematic Review, Brief Research Report, Perspective, Opinion, Study Protocol, and Case Report.

Topic Coordinator, Jesús Emilio Barrueco Francioni, has received speaker honoraria from Vantive (formerly Baxter Kidney Care). Topic Editor, José J. Zaragoza, has received occasional speaker honoraria from B. Braun, exclusively for academic talks and educational lectures on CRRT. The other Topic Editors declare no competing interests with regard to the Research Topic subject.

Article types and fees

This Research Topic accepts the following article types, unless otherwise specified in the Research Topic description:

• Brief Research Report
• Case Report
• Classification
• Clinical Trial
• Data Report
• Editorial
• FAIR² Data
• General Commentary
• Hypothesis and Theory
• ... View all formats

Articles that are accepted for publication by our external editors following rigorous peer review incur a publishing fee charged to Authors, institutions, or funders.

Article types

This Research Topic accepts the following article types, unless otherwise specified in the Research Topic description:

• Brief Research Report
• Case Report
• Classification
• Clinical Trial
• Data Report
• Editorial
• FAIR² Data
• General Commentary
• Hypothesis and Theory
• Methods
• Mini Review
• Opinion
• Original Research
• Perspective
• Review
• Study Protocol
• Systematic Review
• Technology and Code

Keywords: acute kidney injury, renal replacement therapy, continuous renal replacement therapy, intermittent hemodialysis, dialysis dose, critical care nephrology, healthcare disparities

Important note: All contributions to this Research Topic must be within the scope of the section and journal to which they are submitted, as defined in their mission statements. Frontiers reserves the right to guide an out-of-scope manuscript to a more suitable section or journal at any stage of peer review.