Comparing Renal Replacement Therapy Modalities in Critically Ill Patients With Acute Kidney Injury: A Systematic Review and Network Meta-Analysis

Ye, Zhikang; Wang, Ying; Ge, Long; Guyatt, Gordon; Collister, David; Alhazzani, Waleed; Bagshaw, Sean M.; Belley‐Côté, Emilie P.; Fang, Fang; Hou, Liangying; Kolb, Philipp; Lamontagne, François; Oczkowski, Simon; Pyne, Lonnie; Rabbat, Christian G.; Scaum, Matt; Najafabadi, Borna Tadayon; Tangamornsuksan, Wimonchat; Wald, Ron; Wang, Qi; Walsh, Michael; Yao, Liang; Zeng, Linan; Algarni, Abdullah; Couban, Rachel; Alexander, Paul; Rochwerg, Bram

doi:10.1097/cce.0000000000000399

Cited by 25 publications

(23 citation statements)

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“…Many aspects of RRT in ICU patients remain controversial including the effect of modality on renal recovery [ 14 – 16 ]. Yet, it is clinically plausible that RRT modality might affect this outcome [ 7 , 17 ]. Unfortunately, all previous analyses could not adjust for individual baseline characteristics.…”

Section: Discussionmentioning

confidence: 99%

Renal outcomes according to renal replacement therapy modality and treatment protocol in the ATN and RENAL trials

et al. 2022

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Background In critically ill patients with acute kidney injury, renal replacement therapy (RRT) modality and treatment protocols may affect kidney recovery. This study explored whether RRT modality and treatment protocol affected RRT dependence in the ‘Randomized Evaluation of Normal versus Augmented Level of RRT’ and the ‘Acute Renal Failure Trial Network’ (ATN) trials. Methods Primary outcome was 28-day RRT dependence. Secondary outcomes included RRT dependence among survivors and in different SOFA-based treatment protocol groups. We used the Fine-Gray competing-risk model sub-distribution hazard ratio (SHR) to assess the primary outcome. Analyses were adjusted for confounders. Results Of 2542 patients, 2175 (85.5%) received continuous RRT (CRRT) and 367 (14.4%) received intermittent hemodialysis (IHD) as first RRT modality. CRRT-first patients had greater illness severity. After adjustment, there was no between-group difference in 28-day RRT dependence (SHR, 0.96 [95% CI 0.84–1.10]; p = 0.570) or hospital mortality (odds ratio [OR], 1.14 [95% CI 0.86–1.52]; p = 0.361) However, among survivors, CRRT-first was associated with decreased 28-day RRT dependence (OR, 0.54 [95% CI 0.37–0.80]; p = 0.002) and more RRT-free days (common OR: 1.38 [95% CI 1.11–1.71]). Moreover, among CRRT-first patient, the ATN treatment protocol was associated with fewer RRT-free days, greater mortality, and a fourfold increase in RRT dependence at day 28. Conclusions There was no difference in RRT dependence at day 28 between IHD and CRRT. However, among survivors and after adjustment, both IHD-first and the ATN treatment protocol were strongly associated with greater risk of RRT dependence at 28 days after randomization. Trial registration NCT00221013 registered September 22, 2005, and NCT00076219 registered January 19, 2004.

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Section: Discussionmentioning

confidence: 99%

Renal outcomes according to renal replacement therapy modality and treatment protocol in the ATN and RENAL trials

et al. 2022

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“…A recent metaanalysis demonstrated that extracorporeal dialysis probably increased the risk of hypotension compared with PD. 34 Another study suggests that lower ultrafiltration rates during PD compared to extracorporeal dialysis led to better haemodynamic stability. 23,26 We also hypothesised that patients who received PD would have better kidney recovery compared to those who received extracorporeal dialysis.…”

Section: Discussionmentioning

confidence: 99%

“…A recent meta-analysis demonstrated that extracorporeal dialysis probably increased the risk of hypotension compared with PD. 34 Another study suggests that lower ultrafiltration rates during PD compared to extracorporeal dialysis led to better haemodynamic stability. 23,26…”

Section: Discussionmentioning

confidence: 99%

Outcomes of PD for AKI treatment during COVID-19 in New York City: A multicenter study

et al. 2022

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Background: The high incidence of acute kidney injury (AKI) requiring dialysis associated with COVID-19 led to the use of peritoneal dialysis (PD) for the treatment of AKI. This study aims to compare in-hospital all-cause mortality and kidney recovery between patients with AKI who received acute PD versus extracorporeal dialysis (intermittent haemodialysis and continuous kidney replacement therapy). Methods: In a retrospective observational study of 259 patients with AKI requiring dialysis during the COVID-19 surge during Spring 2020 in New York City, we compared 30-day all-cause mortality and kidney recovery between 93 patients who received acute PD at any time point and 166 patients who only received extracorporeal dialysis. Kaplan–Meier curves, log-rank test and Cox regression were used to compare survival and logistic regression was used to compare kidney recovery. Results: The mean age was 61 ± 11 years; 31% were women; 96% had confirmed COVID-19 with median follow-up of 21 days. After adjusting for demographics, comorbidities, oxygenation and laboratory values prior to starting dialysis, the use of PD was associated with a lower mortality rate compared to extracorporeal dialysis with a hazard ratio of 0.48 (95% confidence interval: 0.27–0.82, p = 0.008). At discharge or on day 30 of hospitalisation, there was no association between dialysis modality and kidney recovery ( p = 0.48). Conclusions: The use of PD for the treatment of AKI was not associated with worse clinical outcomes when compared to extracorporeal dialysis during the height of the COVID-19 pandemic in New York City. Given the inherent selection biases and residual confounding in our observational study, research with a larger cohort of patients in a more controlled setting is needed to confirm our findings.

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“…AKI occurs in up to half of all patients admitted to the ICU, and of these patients, 4-13% require RRT [1,3]. While there are various RRT modalities available, including continuous, prolonged, and intermittent, meta-analyses have demonstrated minimal differences in clinical outcomes between these modalities [4]. However, ICU clinicians typically favor treatments of greater than 12 h for hemodynamically unstable patients [5][6][7], as they allow for more gradual fluid removal and solute clearance over the course of the treatments [5,8].…”

Section: Introductionmentioning

confidence: 99%

Extension of Tablo TrEatmeNt Duration (XTEND) study: successful 24 h prolonged therapy with Tablo in critical patients

Zaman¹,

Moore²,

Jellerson³

et al. 2022

BMC Nephrol

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Background The Tablo® Hemodialysis System (Tablo) is an all in one, easy-to-learn device featuring integrated water purification, on demand dialysate production and two-way wireless data transmission and is approved for use in the acute, chronic, and home settings. Prior reports have demonstrated Tablo’s ability to achieve clinical goals, seamlessly integrate into hospitals and reduce cost across a wide range of treatment times. Extension of the Tablo cartridge to 24 h allows prolonged therapy and even greater flexibility for prescribers in the acute setting. The objective is to report on the first ever experience with Tablo prolonged therapy between 12 and 24 h in critically ill patients treated at a single-center ICU. Methods Nursing staff were trained during a single training session on Tablo prolonged therapy. After a run-in period of five treatments, Tablo data were collected via real-time transmission to a cloud-based, HIPAA compliant platform and reviewed by site staff. Dialysis treatment delivery, clinically significant alarms, and clotting events were recorded. Sub-group analysis between COVID-19 positive and negative patients were reported. Results One hundred (100) consecutive Tablo prolonged treatments had a median prescribed treatment time of 24 h and a median achieved treatment time of 21.3 h. Median cartridge usage was 1.3 per treatment. The dialysis treatment time was delivered in 91% of treatments, with 6% ending early due to an alarm, and 3% ending due to clotting. Clinically significant alarms occurred at a median rate of 0.5 per treatment hour with a resolution time of 18 s. Median blood pump stoppage time related to these alarms was 2.3 min per treatment. Blood pump stoppage time was higher in the COVID-19 subgroup when compared to the non-COVID-19 subgroup. Conclusion Tablo successfully achieves prescribed treatment time with minimal therapy interruptions from alarms or cartridge changes. This data demonstrates the effectiveness of Tablo in achieving personalization of treatments necessary for unstable patients and enabling successful delivery of extended therapy with minimal clotting. Tablo’s prolonged therapy meets the needs of critically patients, including COVID-19 positive patients, requiring renal replacement therapy for greater than 12 h.

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Comparing Renal Replacement Therapy Modalities in Critically Ill Patients With Acute Kidney Injury: A Systematic Review and Network Meta-Analysis

Abstract: Supplemental Digital Content is available in the text.

Cited by 25 publications

References 61 publications

Renal outcomes according to renal replacement therapy modality and treatment protocol in the ATN and RENAL trials

Renal outcomes according to renal replacement therapy modality and treatment protocol in the ATN and RENAL trials

Outcomes of PD for AKI treatment during COVID-19 in New York City: A multicenter study

Extension of Tablo TrEatmeNt Duration (XTEND) study: successful 24 h prolonged therapy with Tablo in critical patients

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