Continuous Renal Replacement Therapy (CRRT) or Intermittent Hemodialysis (IHD)—What Is the Procedure of Choice in Critically Ill Patients?

Abstract

Although at present there is no prospective randomized study which could show significantly better survival of patients on continuous procedures, the majority of intensivists advocate this technique of renal function replacement due to generally accepted opinion that it has less effect on circulation of already hemodynamically unstable patients. In our prospective randomized study with 104 patients, we also did not observe any difference in 28 days survival, in total survival, as well as in circulatory instability between two treatment modalities. Even in subgroup of 80 patients with sepsis and septic shock there were no difference in survival. Sepsis was the underlying disorder in 52 and septic shock in 28 patients out of 104 patients analyzed in this study. Our prospective randomized study did not show a statistically significant difference between the two methods of renal replacement therapy. Survival rates were not affected and neither was the occurrence of hemodynamic instability. We believe that both methods are complementary; IHD for faster elimination of electrolytes and waste products elimination, CRRT for regulation of higher calories requirements and for hemodynamically unstable patients. The expectations that one method is superior to the other in the term of better survival have not been corroborated by the current data available in the literature. The choice of the method should be individualized. ARF, which is an integral part of MOF, is a problem frequently encountered in critically ill patient treated in the ICU, but outcome of these patients depends closely on the control of basic event. Evaluation of each of the supportive procedures is therefore hindered by the fact that the underlying disease has the crucial effect on survival and the type of supportive procedure less so.

Trends in Dialysis Modality for Individuals with Acute Kidney Injury

“…[19,[31][32][33] A similar concept may explain the relatively higher mortality rate observed in patients on DHD as compared to those on IHD. The comparable outcomes of IHD and CRRT in randomized trials [23][24][25][26][27][28][29][30] suggest that the higher mortality observed with CRRT in our report is a reflection of severity of underlying diseases and comorbidities rather than complication of dialysis modalities.…”

The Japanese Clinical Practice Guidelines for Management of Sepsis and Septic Shock 2016 (J‐SSCG2016)

“…A total of 15 studies were examined; “in‐hospital mortality” was assessed based on seven RCTs264, 265, 266, 267, 268, 269, 270 and yielded a risk ratio of 1.01 (95% CI: 0.92–1.12); “transition to chronic dialysis” was examined based on three RCTs264, 266, 269 and yielded a risk ratio of 1.01 (95% CI: 0.92–1.07); no difference was observed between apheresis performed continuously and intermittently. Three RCTs269, 270, 271 were also examined with respect to reduction in blood pressure, and no differences in the risk ratio of 0.92 (95% CI: 0.72–1.16) were observed in the studies.…”

Renal replacement therapy for acute kidney injury

“…RCTs comparing these two modalities have failed to provide evidence for the survival benefits of CRRT over IHD [32][33][34][35][36][37][38][39][40][41][42][43][44][45][46]. The clinical question "which is the best treatment strategy for critically ill patients with AKI requiring RRT ?…”

“…Whether high dose of RRT for AKI leads to the improvement of survival and renal recovery remains controversial. In the first study conducted by Ronco et al evaluating the intensity of CRRT, 425 critically ill patients with AKI at a single center in Italy who were treated with continuous veno-venous hemofiltration (CVVHF) were randomized to three groups differing in filtration rate (20,35, or 45 mL/kg/h) [14]. The survival at 15 days after discontinuation of CRRT was significantly lower in the lowest dose (41 %) than in the intermediate (57 %, p = 0.007) and highest (58 %, p = 0.0013) dose groups but did not differ in the latter two groups.…”