Interventions to prevent hemodynamic instability during renal replacement therapy in critically ill patients: a systematic review

Abstract

BackgroundHemodynamic instability related to renal replacement therapy (HIRRT) may increase the risk of death and limit renal recovery. Studies in end-stage renal disease populations on maintenance hemodialysis suggest that some renal replacement therapy (RRT)-related interventions (e.g., cool dialysate) may reduce the occurrence of HIRRT, but less is known about interventions to prevent HIRRT in critically ill patients receiving RRT for acute kidney injury (AKI). We sought to evaluate the effectiveness of RRT-related interventions for reducing HIRRT in such patients across RRT modalities.MethodsA systematic review of publications was undertaken using MEDLINE, MEDLINE in Process, EMBASE, and Cochrane’s Central Registry for Randomized Controlled Trials (RCTs). Studies that assessed any intervention’s effect on HIRRT (the primary outcome) in critically ill patients with AKI were included. HIRRT was variably defined according to each study’s definition. Two reviewers independently screened abstracts, identified articles for inclusion, extracted data, and evaluated study quality using validated assessment tools.ResultsFive RCTs and four observational studies were included (n = 9; 623 patients in total). Studies were small, and the quality was mostly low. Interventions included dialysate sodium modeling (n = 3), ultrafiltration profiling (n = 2), blood volume (n = 2) and temperature control (n = 3), duration of RRT (n = 1), and slow blood flow rate at initiation (n = 1). Some studies applied more than one strategy simultaneously (n = 5). Interventions shown to reduce HIRRT from three studies (two RCTs and one observational study) included higher dialysate sodium concentration, lower dialysate temperature, variable ultrafiltration rates, or a combination of strategies. Interventions not found to have an effect included blood volume and temperature control, extended duration of intermittent RRT, and slower blood flow rates during continuous RRT initiation. How HIRRT was defined and its frequency of occurrence varied widely across studies, including those involving the same RRT modality. Pooled analysis was not possible due to study heterogeneity.ConclusionsSmall clinical studies suggest that higher dialysate sodium, lower temperature, individualized ultrafiltration rates, or a combination of these strategies may reduce the risk of HIRRT. Overall, for all RRT modalities, there is a paucity of high-quality data regarding interventions to reduce the occurrence of HIRRT in critically ill patients.Electronic supplementary materialThe online version of this article (10.1186/s13054-018-1965-5) contains supplementary material, which is available to authorized users.

Fieber in der Intensivmedizin

“…In mehreren der oben bereits dargestellten Studien führte die Fiebersenkung zu einer Verbesserung der hämodynamischen Instabilität. Gerade bei Nierenersatzverfahren auf der Intensivstation scheint ein aktives Temperaturmanagement des Dialysats und des perfundierten Blutes zu einer verminderten Häufigkeit der verfahrensassoziierten hämodynamischen Instabilität beizutragen [15].…”

Continuous Renal Replacement Therapy Specialized Teams: A Challenge to Improve Quality Performance

“…International registries show that about 13% of ICU patients with AKI may require renal replacement therapies, and the mortality rate in this group could be up to 50% [8,9]. The high mortality rate in this population reflects the critical state and the development of multiorgan failure.…”

Continuous renal replacement therapy in Iran; current practice, indications and outcomes in hemodynamically unstable patients

“…Using CRRT as a viable RRT has increased over the past two decades (19)(20)(21). A recent study has suggested the CRRT as the preferred RRT in AKI patients (24)(25)(26)(27)(28)(29). In patients with liver disease and intracranial hypertension, CRRT has provided better control on the fluid balance than IHD (30,31).…”

“…Furthermore, patients need to remain immobilized during the procedure which is a disadvantage (22,23). Hemodynamic instability is a major complication that may lead to early termination of IHD and increased likelihood of morbidity and mortality in patients undergoing dialysis (2,25,26). Different dialysis methods represent variable therapeutic costs, complications, and limitations.…”