Table 1.

Best practice recommendations for prescription of continuous kidney replacement therapy (CKRT) in COVID-19 patients based on the experience in different hospitals in London and The American Society of Nephrology (ASN) and pCRRT foundation recommendations.^{11, 12}

1. Indication: fluid overload, azotemia, electrolyte imbalance (CKRT might have to be initiated at a later stage of AKI rather than early)

2. Reduce exposure to healthcare professionals: To avoid exposure to healthcare staff, CRRT machine can be set outside the isolation room using extended tubing (risk of more frequent disconnections, more priming volume required, hence might not be a feasible option in children)

3. Timing of initiation: There is no evidence to initiate RRT early, especially when resources are limited, STARRT AKI study refutes the advantage of accelerated versus standard timing of initiation of CKRT in critically ill adults

4. Vascular access: largest possible catheter in the right internal jugular vein under ultrasound guidance (best site to access when patient is in the prone position for respiratory failure, catheter-related issues like bending, kinking can also be avoided in this site)

5. Priming solution: Blood, saline, albumin depending on local policy

6. Blood flow rate: based on weight and age of the child as per standard non-COVID guidelines, might have to be increased to prevent excessive filter clotting

7. Filter size: as per size of the patient, might have to increase the size to prevent thrombosis.

8. Circuit and blood line set: as standard, depending on resources, we might have to adapt to ‘whatever’ is available and safe

9. Dialysate/Replacement fluid dose: If fluids and CKRT machines are available—use standard recommended dose; if fluids are in short supply, use lesser exchange rates for 24 h. If fluids in extreme shortage—fluids from different machines can be interchangeably used. Some centers manufacture their own dialysis fluid

10. Net ultrafiltration rate: 1−2 ml/kg/h after the patient is haemodynamically stable

11. Anticoagulation: most important aspect of CKRT in COVID-19 due to frequent filter clotting due to hyper-coagulable state—unfractionated heparin (UFH), regional citrate anticoagulation (RCA), prostacyclin, low molecular weight heparin (LMWH) most commonly used either systemically, regionally or combination of the 2. If filter life still low, a combination of anticoagulants can be used (UFH + RCA/ UFH + citrate/LMWH + RCA)

12. Stopping CRRT: same principles as used for non-COVID, might have to change criteria to give filter holiday to spare the machines for other patients who could not be offered CRRT

13. Drug dose alteration: standard principles to follow; information on drugs used on CKRT in COVID-19 patients—ramdesevir, tocilizumab, not yet available