Timing of renal replacement therapy initiation by AKIN classification system

Leite, Tacyano Tavares; Macedo, Etienne; Pereira, Samuel Montenegro; Bandeira, Sandro R C; Pontes, Pedro H S; Garcia, André S; Militão, Fernanda; Sobrinho, Irineu M M; Assunção, Livia M; Libório, Alexandre Braga

doi:10.1186/cc12593

Cited by 49 publications

(38 citation statements)

References 26 publications

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“…A preliminary conclusion we could reach is that RRT must be initiated only in patients with AKI with complications; however, several studies have suggested that early RRT initiation can have some advantages (28,29). Considering the studies evaluating the use of early RRT, we suggest that our challenge now is to recognize those patients prone to developing AKI-related complications early in the treatment course.…”

Section: Discussionmentioning

confidence: 96%

AKI Complications in Critically Ill Patients

Libório

Leite

Neves

et al. 2015

Clinical Journal of the American Society of Nephrology

111

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Background and objectives AKI is associated with short-and long-term mortality. However, the exact contribution of AKI complications to the burden of mortality and whether RRT has any beneficial effect on reducing mortality rates in critically ill AKI patients are unknown.Design, setting, participants, & measurements This was a retrospective analysis using data from the Multiparameter Intelligent Monitoring in Intensive Care II project. A total of 18,410 adult patients were enrolled from four intensive care units from a university hospital from 2001 to 2008.Results Overall, 10,245 patients developed AKI. After adjustments, the odds ratios (ORs) for hospital mortality were 1.73 (95% confidence interval [95% CI], 1.52 to 1.98) for AKI stage 1, 1.88 (95% CI, 1.57 to 2.25) for stage 2, and 2.89 (95% CI, 2.41 to 3.46) for stage 3. Totals of 33%, 59%, and 70% of the excess mortality rates associated with AKI stages 1, 2, and 3, respectively, were attenuated by the inclusion of each AKI-related complication in the model. The main burden of excess hospital mortality associated with AKI was attenuated by metabolic acidosis and cumulative fluid balance. Long-term mortality was not attenuated by any of the associated complications. Next, we used two different approaches to explore the associations between RRT, AKI complications, and hospital mortality: multivariate analysis and propensity score matching. In both approaches, the sensitivity analysis for RRT was associated with a better hospital survival in only the following AKI-related subgroups: hyperkalemia (OR, 0.55; 95% CI, 0.35 to 0.85), metabolic acidosis (OR, 0.70; 95% CI, 0.53 to 0.92), cumulative fluid balance .5% of body weight (OR, 0.60; 95% CI, 0.40 to 0.88), and azotemia (OR, 0.57; 95% CI, 0.40 to 0.81).Conclusions A majority of the excess risk of mortality associated with AKI was attenuated by its fluid volume and metabolic complications, particularly in severe AKI. In addition, this study demonstrated that RRT is associated with a better outcome in patients with AKI-related complications.

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Section: Discussionmentioning

confidence: 96%

AKI Complications in Critically Ill Patients

Libório

Leite

Neves

et al. 2015

Clinical Journal of the American Society of Nephrology

111

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“…Data from meta-analyses suggest that initiating RRT in a pre-emptive fashion according to arbitrary definitions, such as serum urea concentration or duration of oliguria or anuria, may be beneficial (2,3). Observational studies have reported better outcomes for patients who initiated RRT with milder stages of AKI (4,5) or within 24 hours of stage 3 AKI diagnosis (6). However, in a small randomized controlled trial (RCT), pre-emptive RRT after the discovery of oliguric AKI was not shown to improve survival compared with RRT initiation on the basis of clinical indications (7).…”

Section: Introductionmentioning

confidence: 99%

Timing of RRT Based on the Presence of Conventional Indications

Vaara

Reinikainen

Wald

et al. 2014

Clinical Journal of the American Society of Nephrology

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Background and objectives No data on the development of conventional indications for RRT (refractory acidosis, hyperkalemia, uremia, oliguria/anuria, and volume overload) related to timing of RRT exist. The prevalence of conventional indications among critically ill patients on RRT for AKI was evaluated, and patients manifesting indications versus patients without indications were compared in terms of crude and adjusted 90-day mortality.Design, setting, participants, & measurements In this substudy of the Finnish Acute Kidney Injury study conducted in 2011 and 2012 in 17 intensive care units with 2901 patients, patients were classified as pre-emptive (no conventional indications) and classic (one or more indications) RRT recipients. Patients with classic RRT were divided into classic-urgent (RRT initiated #12 hours from manifesting indications) and classic-delayed (RRT .12 hours from first indication). Additionally, 2450 patients treated without RRT were matched to patients with preemptive RRT.Results Of 239 patients treated with RRT, 134 (56.1%; 95% confidence interval [95% CI], 49.8% to 62.4%) fulfilled at least one conventional indication before commencing RRT. Crude 90-day mortality of 134 patients with classic RRT was 48.5% (95% CI, 40.0% to 57.0%), and it was 29.5% (95% CI, 20.8% to 38.2%) for the 105 patients with preemptive RRT. Classic RRT was associated with a higher risk for mortality (adjusted odds ratio, 2.05; 95% CI, 1.03 to 4.09). Forty-four patients with classic-delayed RRT showed higher crude mortality (68.2%; 95% CI, 54.4% to 82.0%) compared with patients with classic-urgent RRT, and this association persisted after adjustment for known confounders (odds ratio, 3.85; 95% CI, 1.48 to 10.22). Crude 90-day mortality of 67 1:1 matched patients with pre-emptive RRT was 26.9% (95% CI, 6.3% to 37.5%), and it was 49.3% (95% CI, 37.3% to 61.2%; P=0.01) for their non-RRT matches.Conclusions Patients on RRT after one or more conventional indications had both higher crude and adjusted 90-day mortality compared with patients without conventional indications. These findings require confirmation in an adequately powered, multicenter, randomized controlled trial.

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“…An argument has been made by Ronco et al [17] that this study, along with other recent observational studies [21,23] supports a conclusion that, while early initiation may or may not be beneficial, avoiding or delaying it is associated with increased mortality. We do not agree that this has been clearly established given that recent studies do not consistently report either that delaying or avoiding RRT is harmful, or that earlier initiation is harmless [30][31][32][33][34][35][36] .…”

Section: Insufficient Evidence To Support Ever Earlier Rrtmentioning

confidence: 67%

“…While consensus has been established that RRT should be initiated for 'conventional', potentially lifethreatening indications, the threshold for starting has been lowered such that many patients begin RRT preemptively. Despite this change in practice, there was insufficient evidence to support it: multiple observational studies have suggested decreased mortality with 'earlier' RRT [11,[21][22][23], but many others have suggested that there is no effect [33,36] or that a conservative strategy is superior [30,32,34,35] . In addition, 3 underpowered RCTs have been conducted and none of them have shown significantly improved outcomes with relatively earlier RRT initiation [20,37,38] .…”

Section: Discussionmentioning

confidence: 99%

“…The threshold to initiate of RRT has been lowered relative to what previously constituted consensus regarding 'conventional' indications. As others have suggested [1,7,20] , changing practice likely relates, in part, to the publication of observational studies that reported that the earlier initiation of RRT may be associated with better outcomes [11,[21][22][23] . This phenomenon was noted to occur previously with respect to dialysis initiation for end-stage kidney disease [24] when a change in practice to earlier initiation was triggered by observational studies but ultimately not found to be associated with improved outcomes [25] .…”

Section: Introductionmentioning

confidence: 99%

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Progressively Earlier Initiation of Renal Replacement Therapy for Acute Kidney Injury Is Unwarranted and Potentially Harmful

Clark

Hiremath²

2016

Blood Purif

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Background: The optimal timing of renal replacement therapy (RRT) initiation for acute kidney injury (AKI) is unknown. There is debate as to whether starting RRT earlier for AKI is superior to starting it only after ‘conventional', life-threatening indications are present. Summary: In recent years, there has been an ongoing trend in clinical practice to initiate RRT for AKI long before indications appear. Observational studies show many patients now begin RRT for AKI in the absence of ‘conventional' indications. While this shift may have been prompted by observational studies suggesting improved outcomes with earlier RRT, there was not sufficient justification for a change in clinical practice: many recent, observational studies suggest that early RRT may not beneficial or may be even harmful. Moreover, none of 3 underpowered RCTs reported to date found ‘early' RRT initiation beneficial. Lowering the threshold for RRT initiation inevitably leads to more patients receiving unnecessary treatment and this is a matter of concern, considering the fact that complications are potentially fatal and RRT is very costly. While we await definitive studies, calls to shift clinical practice back toward the initiation of RRT for ‘conventional', life‐threatening indications only, should be heeded. Key Messages: ‘Earlier' initiation of RRT for AKI is already occurring in clinical practice but is not justified on the basis of the studies to date. Lowering the threshold for initiation leads to more patients receiving unnecessary RRT. RRT has potentially fatal complications and is expensive. While we await definitive trials, RRT should be started only after ‘conventional', life-threatening indications occur and not earlier.

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Timing of renal replacement therapy initiation by AKIN classification system

Cited by 49 publications

References 26 publications

AKI Complications in Critically Ill Patients

AKI Complications in Critically Ill Patients

Timing of RRT Based on the Presence of Conventional Indications

Progressively Earlier Initiation of Renal Replacement Therapy for Acute Kidney Injury Is Unwarranted and Potentially Harmful

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