Management of Renal Replacement Therapy in Acute Kidney Injury

Overberger, Pamela; Pesacreta, Matthew; Palevsky, Paul M.; O’Connor, Theresa; Zhang, Jane H.; Chertow, Glenn M.; Crowley, Susan T.; Dev, Devasmita; Kellum, John A.; Paganini, Emil P.; Schein, Roland M. H.; Thompson, B. Taylor; Smith, Mark W.; Swanson, Kathy; Peduzzi, Peter; Star, Robert A.; Young, Eric W.; Lohr, James W.; Dolson, George M.; Bacallao, Robert L.; Shaver, May Jo; Kraut, Jeffrey A.; İkizler, T. Alp; Batuman, Vecihi; Mohan, Ramkumar; Watnick, Suzanne; Feldman, George M.; Gabbai, Francis B.; Johansen, Kirsten L.; Rosado‐Rodriguez, Carlos; Andress, Dennis L.; Rabb, Hamid; Niles, John L.; Contreras, Gabriel; Aslam, Nabeel; Finkel, Kevin W.; Shaw, Andrew; Rocco, Michael V.; Vijayan, Anitha

doi:10.2215/cjn.00780207

Cited by 107 publications

(77 citation statements)

References 20 publications

(19 reference statements)

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“…[11] In the most recent survey of 130 practitioners from 27 sites in the United States, IHD and CRRT were used in 57 and 36% of patients with AKI needing dialysis, respectively. [12] A number of new randomized controlled trials have challenged differing survival benefits for various RRT modalities. Until recently, it had been suggested that greater dialysis clearance either by CRRT or daily hemodialysis [8,13] was associated with improved patient survival compared to conventional dialysis patterns.…”

Section: F Afshinnia Et Almentioning

confidence: 99%

Trends in Dialysis Modality for Individuals with Acute Kidney Injury

Afshinnia

Straight

Li³

et al. 2009

Renal Failure

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Backgrounds. There are no national level data on types of dialysis in use for acute kidney injury (AKI). We aimed to assess trends in dialysis modality for AKI and mortality associated with each modality from 1998 to 2005. Methods. Using data from the 5% Medicare cohort, we identified individuals with AKI requiring dialysis. Individuals with preexisting end-stage renal disease were excluded. Intermittent hemodialysis (IHD), daily intermittent hemodialysis, and continuous renal replacement therapy (CRRT) were defined using Current Procedure Terminology codes. Mortality was defined as death during 30 days after the first dialysis session. Results. Between 1998 and 2005, there were a total of 18,249 patients identified with AKI requiring renal replacement therapy. CRRT was increasingly used for AKI, with 9.9% of patients in 1998 to 18.3% by 2005. Proportion of daily dialysis decreased during this period, while use of IHD remained stable at approximately 68%. Overall 30-day mortality declined from 44.4% in 1998 to 40.2% in 2005.Crude mortality for CRRT was highest in all years (51.0-61.8%), followed by daily (38.2-49.9%) and IHD groups (35.8-43.4%). Multinomial logistic regression analysis showed that white race, presence of sepsis, atherosclerotic heart diseases, peripheral vascular diseases, dysrhythmia, gastrointestinal and liver diseases, and any year after 2000 were independently associated with higher odds of using CRRT after adjusting for other variables. Conclusion. The proportion of patients using CRRT has increased over time. Mortality associated with IHD has decreased from 1998 to 2005. Mortality associated with different dialysis modalities is likely the result of severity of illness.

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Section: F Afshinnia Et Almentioning

confidence: 99%

Trends in Dialysis Modality for Individuals with Acute Kidney Injury

Afshinnia

Straight

Li³

et al. 2009

Renal Failure

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“…3 There are wide practice variations in CRRT that is delivered to the critically ill patient with no consensus on the modality, timing of initiation, frequency, dosing, or duration. 4 Additionally, other factors such as fluid resuscitation, training of caregivers, and the performance standards of CRRT apparatus vary considerably. 1,5,6 Clinicians who initiate CRRT for ARF are often confronted with a dilemma regarding the optimal prescribed CRRT dosage.…”

Section: Introductionmentioning

confidence: 99%

The dose of continuous renal replacement therapy for acute renal failure: a systematic review and meta-analysis

et al. 2010

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Objectives: To conduct a systematic review of the literature to summarize the best available evidence regarding the mortality and morbidity associated with differing dosing regimens of continuous renal replacement therapy (CRRT) for patients with acute renal failure (ARF) in an intensive care unit setting. Patients and Methods: We searched for randomized controlled trials in electronic databases from January 1990 through November 2009. Eligible trials compared two or more dosing regimens of CRRT in patients with ARF. Two reviewers working independently determined trial eligibility and extracted descriptive, methodological, and outcome data. Random-effects meta-analysis was used to assess relative risks (RR) and weighted mean difference. The I 2 -statistic was used to assess heterogeneity of treatment effect across trials. Results: Seven trials were eligible for meta-analysis. We found no reduction in mortality in patients who received higher doses of CRRT (RR 0.88, 95% CI 0.75-1.03, I 2 = 74%). There was no difference in the requirement of renal replacement therapy at the conclusion of the study period (RR 1.12, 95% CI 0.86-1.46, I 2 = 3%). The overall quality of evidence was downgraded because of imprecision and heterogeneity. Conclusion: Increased dosing of CRRT is not associated with a decrease in mortality of patients with ARF in an intensive care unit setting.

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“…25 These results do not imply that the dose of renal-replacement therapy is not important in critically ill patients with acute kidney injury. The less-intensive treatment strategy in our study provided a dose of renal-replacement therapy that exceeded that in usual care, particularly for intermittent hemodialysis.…”

Section: Discussionmentioning

confidence: 92%

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

2009

N Engl J Med

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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

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Management of Renal Replacement Therapy in Acute Kidney Injury

Cited by 107 publications

References 20 publications

Trends in Dialysis Modality for Individuals with Acute Kidney Injury

Trends in Dialysis Modality for Individuals with Acute Kidney Injury

The dose of continuous renal replacement therapy for acute renal failure: a systematic review and meta-analysis

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

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