Continuous renal replacement therapy versus intermittent hemodialysis as first modality for renal replacement therapy in severe acute kidney injury: a secondary analysis of AKIKI and IDEAL-ICU studies
Stéphane GaudryFrançois GrolleauSaber Davide BarbarLaurent Martin‐LefèvreBertrand PonsÉric BouletAlexandre BoyerGuillaume ChevrelFlorent MontiniJulien BohéJulio BadiéJean‐Philippe RigaudChristophe VinsonneauRaphaël PorcherJean‐Pierre QuenotDidier Dreyfuss
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Abstract Background Intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) are the two main RRT modalities in patients with severe acute kidney injury (AKI). Meta-analyses conducted more than 10 years ago did not show survival difference between these two modalities. As the quality of RRT delivery has improved since then, we aimed to reassess whether the choice of IHD or CRRT as first modality affects survival of patients with severe AKI. Methods This is a secondary analysis of two multicenter randomized controlled trials (AKIKI and IDEAL-ICU) that compared an early RRT initiation strategy with a delayed one. We included patients allocated to the early strategy in order to emulate a trial where patients would have been randomized to receive either IHD or CRRT within twelve hours after the documentation of severe AKI. We determined each patient’s modality group as the first RRT modality they received. The primary outcome was 60-day overall survival. We used two propensity score methods to balance the differences in baseline characteristics between groups and the primary analysis relied on inverse probability of treatment weighting. Results A total of 543 patients were included. Continuous RRT was the first modality in 269 patients and IHD in 274. Patients receiving CRRT had higher cardiovascular and total-SOFA scores. Inverse probability weighting allowed to adequately balance groups on all predefined confounders. The weighted Kaplan–Meier death rate at day 60 was 54·4% in the CRRT group and 46·5% in the IHD group (weighted HR 1·26, 95% CI 1·01–1·60). In a complementary analysis of less severely ill patients (SOFA score: 3–10), receiving IHD was associated with better day 60 survival compared to CRRT (weighted HR 1.82, 95% CI 1·01–3·28; p < 0.01). We found no evidence of a survival difference between the two RRT modalities in more severe patients. Conclusion Compared to IHD, CRRT as first modality seemed to convey no benefit in terms of survival or of kidney recovery and might even have been associated with less favorable outcome in patients with lesser severity of disease. A prospective randomized non-inferiority trial should be implemented to solve the persistent conundrum of the optimal RRT technique.Keywords:
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Sepsis is the leading cause of acute kidney injury (AKI) in the intensive care unit. As the most common treatment of septic AKI, it is believed that continuous renal replacement therapy (CRRT) can not only maintain the water balance and excrete the metabolic products but also regulate the inflammation and promote kidney recovery. CRRT can remove the inflammatory cytokines to regulate the metabolic adaption in kidney and restore the kidney recovery to protect the kidney in septic AKI. Second, CRRT can provide extra energy supply in septic AKI to improve the kidney energy balance in septic AKI. Third, the anticoagulant used in CRRT also regulates the inflammation in septic AKI. CRRT is not only a treatment to deal with the water balance and metabolic products, but also a method to regulate the inflammation in septic AKI. Video Journal Club ‘Cappuccino with Claudio Ronco’ at https://www.karger.com/Journal/ArticleNews/223997?sponsor=52.
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急性腎障害（acute kidney injury：AKI）は人口の高齢化に伴い年々増加しており，予後も種々の努力にもかかわらず最近十数年でほとんど改善されていない．また，AKIに対する腎代替療法（renal replacement therapy：RRT）に関しても未だ開始基準，中止基準，方法についてコンセンサスは得られていないのが現状である．本稿ではAKIに対するRRT（特に持続的（continuous）なRRT（CRRT））を中心について最近の知見を含め概説する．
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Despite substantial advances in dialytic techniques and machines, acute kidney injury (AKI) requiring renal replacement therapy (RRT) is associated with up to 60% in-hospital mortality. But, there is no full detail of definite RRT to overcome the significant morbidity and mortality of AKI. What is most important in the treatment for AKI is that RRT is not a cause-specific therapy but a life-supportive management. This review discusses the indications of, proper initiation of, and optimal prescription for RRT to improve the survival of the patients with AKI. (Korean J Med 2012;82:17-21) Keywords: Renal replacement therapy; Acute kidney injury ì¤ì¬ ë¨ì´: ëì¹ ìë²; ê¸ì± ì ìì
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Acute kidney injury (AKI) is increasingly common in critically ill patients and many patients with severe kidney injury require continuous renal replacement therapy (CRRT). However, little is known regarding the incidence rate and associated factors for developing chronic kidney disease after CRRT in AKI patients. This study aimed to investigate renal outcome and the factors associated with incomplete renal recovery in AKI patients who received CRRT.
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ABSTRACT Aim To investigate the impact of renal replacement therapy (RRT) on 90‐day mortality in critically ill patients suffering from KDIGO stage 3 acute kidney injury (AKI) with or without life‐threatening complications using propensity score matching analysis. Methods We conducted a retrospective analysis of critically ill adult patients with KDIGO Stage 3 AKI with or without RRT during ICU stay between 1/1/2011‐31/12/2013. Cox regression analysis and propensity score matching methods were used to determine predictors for 90‐day mortality. Results Among 661 patients, 50.5% received RRT. The unadjusted 90‐day mortality rate was 42.5% and 54.1% in patients who had or had not received RRT, respectively. After adjustment with propensity score based on the probability of receiving RRT, the cox regression analysis showed that RRT was associated with a lower 90‐day mortality (p<0.001). Among 322 propensity‐matched pairs, RRT was associated with lower ICU (23.6% vs. 39.8%, p=0.002), hospital (33.5% vs. 55.9%, p<0.001) and 90‐day mortality (34.2% vs. 58.4%, p<0.001), and a higher 90‐day renal recovery rate (57.8% vs. 45.3% full recovery, p=0.026) compared with no RRT. When an alternate propensity model was used, the benefits associated with RRT were very similar, except 90‐day renal recovery became insignificant. Conclusion Our observational study found that in critically ill patients with KDIGO Stage 3 AKI, RRT may be associated with lower 90‐day mortality. The benefit of RRT on renal recovery was less prominent. Medical futility and practice variations may complicate study interpretation. To avoid these limitations, large‐scale multicenter, non‐observational study is recommended.
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Nearly 60% of patients admitted to intensive care units have evidence of acute kidney injury (AKI). In the recent AKI EPI study, 13.5% of patients admitted to ICUs were treated with renal replacement therapy (RRT) and 23.5% of patients with AKI required RRT (1).
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Introduction The timing of renal replacement therapy (RRT) initiation in patients having acute kidney disease has been a controversial issue for many years. A recently published systematic review and meta-analysis on this topic failed to demonstrate measurable benefits of early RRT. Patients and methods We compared RRT initiation timing in critically ill patients and defined early or late RRT in reference to the timing after which stage 3 Acute Kidney Injury Network criteria were met. Patients beginning RRT within 24 h after reaching stage 3 acute kidney injury (AKI) were considered early starters, whereas those beginning RRT past 24 h after reaching stage 3 AKI were considered late starters. Acute Kidney Injury Network criteria were evaluated by both urine output and serum creatinine. Patients with acute-on-chronic kidney disease were excluded. A propensity score methodology was used to control variables. Results A total of 123 critically ill patients were subjected to RRT. Only 40 patients with pure stage 3 AKI were analyzed. Mortality was lower in the early RRT group than in the late RRT group (18.6 vs. 81.1%, P=0.000). Moreover, patients in the early RRT group had a lower duration of mechanical ventilation, RRT duration, vasopressor duration, and ICU discharge creatinine level. Conclusion Using a time-based approach could be a better means of assessing the association between RRT initiation and outcomes in patients with AKI. In patients with stage 3 AKI, RRT initiation within 24 h should be considered.
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Acute kidney injury (AKI) is a complex syndrome with a high incidence and considerable morbidity in critically ill patients. Renal replacement therapy (RRT) remains the mainstay of treatment for AKI. There are at present multiple disparities in uniform definition, diagnosis, and prevention of AKI and timing of initiation, mode, optimal dose, and discontinuation of RRT that need to be addressed. The Indian Society of Critical Care Medicine (ISCCM) AKI and RRT guidelines aim to address the clinical issues pertaining to AKI and practices to be followed for RRT, which will aid the clinicians in their day-to-day management of ICU patients with AKI.Mishra RC, Sodhi K, Prakash KC, Tyagi N, Chanchalani G, Annigeri RA, et al. ISCCM Guidelines on Acute Kidney Injury and Renal Replacement Therapy. Indian J Crit Care Med 2022;26(S2):S13-S42.
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