Intensity of Renal Support in Critically Ill Patients with Acute Kidney Injury

Abstract

BACKGROUND-The optimal intensity of renal-replacement therapy in critically ill patients with acute kidney injury is controversial.METHODS-We randomly assigned critically ill patients with acute kidney injury and failure of at least one nonrenal organ or sepsis to receive intensive or less intensive renal-replacement therapy. The primary end point was death from any cause by day 60. In both study groups, hemodynamically stable patients underwent intermittent hemodialysis, and hemodynamically unstable patients underwent continuous venovenous hemodiafiltration or sustained low-efficiency dialysis. Patients receiving the intensive treatment strategy underwent intermittent hemodialysis and sustained lowefficiency dialysis six times per week and continuous venovenous hemodiafiltration at 35 ml per kilogram of body weight per hour; for patients receiving the less-intensive treatment strategy, the corresponding treatments were provided thrice weekly and at 20 ml per kilogram per hour.RESULTS-Baseline characteristics of the 1124 patients in the two groups were similar. The rate of death from any cause by day 60 was 53.6% with intensive therapy and 51.5% with less-intensive therapy (odds ratio, 1.09; 95% confidence interval, 0.86 to 1.40; P = 0.47). There was no significant difference between the two groups in the duration of renalreplacement therapy or the rate of recovery of kidney function or nonrenal organ failure. Hypotension during intermittent dialysis occurred in more patients randomly assigned to receive intensive therapy, although the frequency of hemodialysis sessions complicated by hypotension was similar in the two groups.CONCLUSIONS-Intensive renal support in critically ill patients with acute kidney injury did not decrease mortality, improve recovery of kidney function, or reduce the rate of nonrenal organ failure as compared with less-intensive therapy involving a defined dose of intermittent hemodialysis three times per week and continuous renal-replacement therapy at 20 ml per kilogram per hour. (ClinicalTrials.gov number, NCT00076219.) Acute kidney injury is a common complication of acute illness, affecting approximately 2 to 7% of hospitalized patients 1-4 and more than 35% of critically ill patients. 5-8 Renalreplacement therapy is the mainstay of supportive treatment of patients with severe acute kidney injury; its use is required in 5 to 6% of critically ill patients and is associated with inhospital mortality rates of 50 to 80%. 5,9-12 * The affiliations of the members of the writing committee and the members of the VA/NIH Acute Renal Failure Trial Network are listed in the Appendix. The members of the writing committee

Focus on oliguria during renal replacement therapy

“…Two large randomized controlled trials, the ATN Study and the RENAL Study, both showed that more intensive RRT did not have any beneficial effects on renal recovery, nonrenal organ failure or mortality compared with less intensive RRT [62,63]. In a meta-analysis, Wang Y el at found that patients remained RRT dependent for longer while receiving higher intensity RRT(a prescribed dose of 35-48 mL/kg/h), compared with standard intensity(a prescribed dose of 20-25 mL/kg/h), in the first 28 days of treatment, which appears to delay renal recovery [64].…”

Timing of Initiation of Kidney Replacement Therapy in Acute Kidney Injury in the Critically Ill Patient

“…After reaching consensus on the definition of AKI by the Acute Disease Quality Initiative (ADQI) group, the AKI incidence in the general ward has been 20% [5], with rates increasing by approximately 10% per year [6]. The incidence of AKI in the intensive care unit (ICU) has been 30 to 50%, and 10% require kidney replacement therapy (KRT) [7,8]. The hospital mortality of AKI has been 27.5% in those who did not require KRT and from 33 to 53% [9] in those who required KRT.…”