Heterogeneity of Effect of Net Ultrafiltration Rate among Critically Ill Adults Receiving Continuous Renal Replacement Therapy

Abstract

<b><i>Introduction:</i></b> In continuous renal replacement therapy (CRRT)-treated patients, a net ultrafiltration (NUF) rate >1.75 mL/kg/h has been associated with increased mortality. However, there may be heterogeneity of effect of NUF rate on mortality, according to patient characteristics. <b><i>Methods:</i></b> To investigate the presence and impact of heterogeneity of effect, we performed a secondary analysis of the “Randomized Evaluation of Normal versus Augmented Level of Renal Replacement Therapy” (RENAL) trial. Exposure was NUF rate (weight-adjusted fluid volume removed per hour) stratified into tertiles (<1.01 mL/kg/h; 1.01–1.75 mL/kg/h; or >1.75 mL/kg/h). Primary outcome was 90-day mortality. Patients were clustered according to baseline characteristics. Heterogeneity of effect was assessed according to clusters and baseline edema and related to the additional impact of baseline cardiovascular Sequential Organ Failure Assessment (SOFA) score. We excluded patients with missing values for baseline weight and/or treatment duration. <b><i>Results:</i></b> We identified 2 clusters. The largest (cluster 1; <i>n</i> = 941) included more severely ill patients, with more sepsis, more edema, and more vasopressor therapy (all <i>p</i> < 0.001). Compared to the middle tertile, the probability of harm was greater with the high tertile of NUF rate in patients in cluster 1 and in patients with baseline edema (probability of harm, cluster 1: 99.9%; edema: 99.1%). Moreover, higher baseline cardiovascular SOFA score also increased mortality risk with both high and low compared to middle NUF rates in cluster 1 patients and in patients with edema. <b><i>Conclusions:</i></b> In CRRT patients, both high and low NUF rates may be harmful, especially in those with edema, sepsis, and greater illness severity. Cardiovascular SOFA scores modulate this association. Additional studies are needed to test these hypotheses, and targeted trials of NUF rates based on risk stratification appear justified. <b><i>Trial Registration:</i></b> ClinicalTrials.gov identifier: NCT00221013.

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“…The investigators concluded that UF NET >1.75 ml/kg per hour was independently associated with increased hospital mortality, and this effect was not mediated by fluid balance, low BP, vasopressor use, hypokalemia, or hypophosphatemia (18). In another study, the investigators evaluated the heterogeneity of effect of UF NET in critically ill patients receiving CKRT and found that both high and low UF NET rates may be harmful, especially in those with edema, sepsis, and greater acuity of illness severity (19). When evaluating kidney recovery, one study found that UF NET >1.75 ml/kg per hour was independently associated with lower kidney recovery rates (20).…”