Timing for Initiation of Continuous Renal Replacement Therapy in Patients With Septic Shock and Acute Kidney Injury

Abstract

The optimal timing for renal replacement therapy initiation in septic acute kidney injury (AKI) remains controversial. This study investigates the impact of early versus late initiation of continuous renal replacement therapy (CRRT) on organ dysfunction among patients with septic shock and AKI. Patients were dichotomized into "early" (simplified RIFLE Risk) or "late" (simplified RIFLE Injury or Failure) CRRT initiation. Patients with chronic kidney disease stage 5 or those on long-term dialysis were excluded. Organ dysfunction was quantified by Sequential Organ Failure Assessment (SOFA) score. From January 2008 to June 2011, 120 patients fulfilled the inclusion criteria. Thirty-one (26%) underwent "early" while 89 (74%) had "late" CRRT. No significant difference was noted between groups on improvement of total SOFA/non-renal SOFA score or noradrenaline equivalent in the first 24 and 48 h after CRRT initiation. Dialysis requirement and mortality (at 28 days, 3 months and 6 months) did not differ. In conclusion, improvement of non-renal SOFA score 48 h after CRRT correlated with SOFA score on CRRT initiation (P = 0.040) and APACHE IV risk of death (P = 0.000), but not estimated glomerular filtration rate on CRRT initiation (P = 0.377). Improvement of non-renal SOFA score correlated with SOFA score on CRRT initiation and APACHE IV risk of death. However, this retrospective review cannot identify any significant clinical benefit of early CRRT initiation in patients presenting with septic shock and AKI.

Long-Term Risk of Progressive Chronic Kidney Disease in Patients with Severe Acute Kidney Injury Requiring Dialysis after Coronary Artery Bypass Surgery

“…Using AKIN stage 3 as a definition for ‘late' start versus AKIN stages 1 and 2 as ‘early start', we did not find an association with mortality or CKD progression. This is consistent with recent studies in critically ill septic AKI patients that found no difference in-hospital mortality when creatinine-based criteria were used to determine ARRT initiation [27,28]. A change in peri-operative serum creatinine levels in critically ill patients may be less reliable as a biomarker of renal injury as it can be influenced by muscle mass, concurrent sepsis, or hemodilution during surgery [29].…”

Renal replacement therapy for acute kidney injury

“…Several studies have examined the timing of RRT initiation in AKI patients in the ICU. It is unclear whether the early initiation of RRT improves survival and renal recovery rates [4][5][6][7][8][9]. These studies, however, differ in their definition of early and late initiation.…”

“…Several observational studies have assessed the relationships between the timing of RRT and mortality and renal recovery in critically ill patients with AKI requiring RRT [6][7][8]. The largest prospective cohort study, involving patients at 54 ICUs in 23 countries, showed that the timing of RRT influenced outcomes in critically ill patients with severe AKI [7].…”

Initiating acute dialysis at earlier Acute Kidney Injury Network stage in critically ill patients without traditional indications does not improve outcome: A prospective cohort study

“…and Ostermann et al . In particular, urine output criterion was included in determining AKIN stages, unlike other studies evaluating creatinine‐only or eGFR‐only RIFLE or AKIN criteria …”