Patient Selection and Timing of Continuous Renal Replacement Therapy

Ostermann, Marlies; Joannidis, Michael; Pani, Antonello; Floris, Matteo; Rosa, Silvia De; Kellum, John A.; Ronco, Claudio

doi:10.1159/000448506

Cited by 146 publications

(130 citation statements)

References 77 publications

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“…Finally, in clinical settings where blood purification requirement is accompanied with multiple organ failure or septic shock, CRRT is recommended [94]. …”

Section: Transition From Ihd or Pd To Crrtmentioning

confidence: 99%

Management of Chronic Kidney Disease Patients in the Intensive Care Unit: Mixing Acute and Chronic Illness

Rosa

Samoni²,

Villa³

et al. 2017

Blood Purif

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3,608

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Patients with chronic kidney disease (CKD) are at high risk for developing critical illness and for admission to intensive care units (ICU). ‘Critically ill CKD patients' frequently develop an acute worsening of renal function (i.e. acute-on-chronic, AoC) that contributes to long-term kidney dysfunction, potentially leading to end-stage kidney disease (ESKD). An integrated multidisciplinary effort is thus necessary to adequately manage the multi-organ damage of those kidney patients and contemporaneously reduce the progression of kidney dysfunction when they are critically ill. The aim of this review is to describe (1) the pathophysiological mechanisms underlying the development of AoC kidney dysfunction and its role in the progression toward ESKD; (2) the most common clinical presentations of critical illness among CKD/ESKD patients; and (3) the continuum of care for CKD/ESKD patients from maintenance hemodialysis/peritoneal dialysis to acute renal replacement therapy performed in ICU and, vice-versa, for AoC patients who develop ESKD.

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“…Finally, in clinical settings where blood purification requirement is accompanied with multiple organ failure or septic shock, CRRT is recommended [94]. …”

Section: Transition From Ihd or Pd To Crrtmentioning

confidence: 99%

Management of Chronic Kidney Disease Patients in the Intensive Care Unit: Mixing Acute and Chronic Illness

Rosa

Samoni²,

Villa³

et al. 2017

Blood Purif

Self Cite

3,608

View full text Add to dashboard Cite

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“…Die optimale Beginn der Nierenersatztherapie beim Intensivpatienten ist nach wie vor eine der ungelösten Forschungsfragen, deren Beantwortung von Experten mit der höchsten Priorität beurteilt wird [18]. Weitgehender Konsens besteht über die absoluten Kriterien zum Therapiebeginn (.…”

Section: Beginn Der Nierenersatztherapieunclassified

“…Auf diesen basiert auch die derzeit allgemein gültige Einteilung der Stadien des ANV. Eine Zunahme der Mortalität kann bei steigendem Schweregrad der Nierenschädigung beobachtet werden (KDIGO 1 -Odds-Ratio, OR: 2,19; 95%-KI: 1, 35;18;04;[7]). Im Durchschnitt benötigen 5-13 % der Intensivpatienten eine Nierenersatztherapie, das entspricht etwa 25 % der Patienten mit ANV [7,19,30].…”

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Nierenersatztherapie im akuten Nierenversagen

Klein

Joannidis

2017

Med Klin Intensivmed Notfmed

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Nierenersatztherapie im akuten NierenversagenTrotz weltweiter Forschungsbemühun-gen in den letzten Jahren zählt das akute Nierenversagen (ANV) bzw. die akute Nierenschädigung ("acute kidney injury", AKI) unverändert zu einer der Komplikationen auf Intensivstationen, die mit hoher Morbidität und Mortalität einhergehen. Im Rahmen der multinationalen AKI-EPI-Studie wurde bei 57,3 % (95 %-Konfidenzintervall [KI] 55,0-29,6) der Intensivpatienten ein ANV festgestellt [7]. Andere Studien gaben bei diesem Patientenkollektiv eine Inzidenz des ANV von 20-50 % an [4,24]. Weltweit sind 13,3 Mio. Menschen jedes Jahr von einem ANV betroffen und es wird angenommen, dass hierdurch jährlich 1,7 Mio. Todesfälle verursacht werden [15]. Die derzeit aktuellste Version der Behandlungsempfehlungen des ANV stellen die Kidney-Disease-Improving-GlobalOutcomes(KDIGO)-Leitlinien aus dem Jahr 2012 dar. Auf diesen basiert auch die derzeit allgemein gültige Einteilung der Stadien des ANV. Eine Zunahme der Mortalität kann bei steigendem Schweregrad der Nierenschädigung beobachtet werden (KDIGO 1 -Odds-Ratio, OR: 2,19; 95%-KI: 1, 35;18;04;[7]). Im Durchschnitt benötigen 5-13 % der Intensivpatienten eine Nierenersatztherapie, das entspricht etwa 25 % der Patienten mit ANV [7,19,30].

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“…Timing of RRT initiation in critically-ill patients: time for precision medicine Eric Kipnis 1 , Francesco Garzotto 2 , Claudio Ronco consensus group (7)(8)(9)(10)(11) suggesting that precision CRRT should start from a truly personalized prescription of timing of initiation of the extracorporeal therapy. This has been derived from several previous observations and the analysis of the literature (12)(13)(14).…”

Section: Editorialmentioning

confidence: 99%

Timing of RRT initiation in critically-ill patients: time for precision medicine

Kipnis¹,

Garzotto²,

Ronco³

2016

J. Thorac. Dis.

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Recently published randomized controlled trials have brought a focus upon the timing of renal replacement therapy (RRT) initiation in critically-ill patients (1,2). The AKIKI study randomized 620 ICU patients with severe acute kidney injury (AKI) [kidney disease improving global outcomes (KDIGO) classification, stage 3] to either immediate initiation of RRT or delayed initiation according to predetermined mandatory RRT criteria (1). Gaudry et al. found no significant difference in mortality between early and delayed RRT initiation strategies in critically-ill patients results, suggesting that careful monitoring of patients for predetermined mandatory RRT criteria may safely allow delaying RRT in ventilated and/or catecholaminedependent patients with severe AKI. To a more detailed unadjusted subpopulation analyses however, it seems that results may have been influenced by differences in patient outcomes within the delayed-RRT group. Indeed, among patients in the delayed group, those without RRT had a significantly decreased risk of death [hazard ratio =0.71 (0.52;0.97); P=0.031] while those who received delayed RRT had significantly increased risk of death [hazard ratio =1.40 (1.08;1.8); P=0.011]. These results suggest that patients who will never have required RRT probably benefit from not being exposed to potential complications of RRT while patients who definitely required RRT suffer from delayed initiation. The authors mitigate these results by performing an adjustment to baseline severity, after which differences were no longer significant. Given the important implications of the unadjusted subpopulation analysis, adjustment to baseline severity may not have been sufficient to completely describe results and the related phenomena. Rather, studies show that even when adjusting for severity, fluid accumulation remains a major risk factor for death in ICU patients with AKI (3-6). Therefore, adjusting-to or stratifying-by fluid accumulation could have confirmed or accentuated the opposite behaviors observed within the delayed-RRT group. Although no data on fluid accumulation was provided aside from pulmonary edema incidence, increased diuretic use in the delayed-RRT group [4 patients (1.3%) vs. 112 patients (36.5%); P<0.001] shows that fluid accumulation was a major issue nonetheless.Fluid accumulation was among inclusion criteria in the recent ELAIN trial which randomized 231 critically-ill patients with AKI (KDIGO stage 2) to either early (within 8 hours of diagnosis of KDIGO stage 2 AKI; n=112) or delayed (within 12 hours of stage 3 AKI or no initiation; n=119) initiation of RRT (2). The use of biomarkers was also among inclusion criteria in the ELAIN trial: plasma neutrophil gelatinase-associated lipocalin (NGAL) >150 ng/mL. Zarbock et al. found increased survival in early versus delayed-RRT suggesting that "early" RRT-initiation earlier than the in the AKIKI trial (KDIGO stage 2 vs. stage 3) in patients with both fluid accumulation and NGAL-positive AKI is beneficial.Given possible risks to patient subpopul...

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Patient Selection and Timing of Continuous Renal Replacement Therapy

Cited by 146 publications

References 77 publications

Management of Chronic Kidney Disease Patients in the Intensive Care Unit: Mixing Acute and Chronic Illness

Management of Chronic Kidney Disease Patients in the Intensive Care Unit: Mixing Acute and Chronic Illness

Nierenersatztherapie im akuten Nierenversagen

Timing of RRT initiation in critically-ill patients: time for precision medicine

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