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Fayad AI, Buamscha DG, Ciapponi A. Timing of kidney replacement therapy initiation for acute kidney injury. Cochrane Database Syst Rev 2022; 11:CD010612. [PMID: 36416787 PMCID: PMC9683115 DOI: 10.1002/14651858.cd010612.pub3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common condition among patients in intensive care units (ICUs) and is associated with high numbers of deaths. Kidney replacement therapy (KRT) is a blood purification technique used to treat the most severe forms of AKI. The optimal time to initiate KRT so as to improve clinical outcomes remains uncertain. This is an update of a review first published in 2018. This review complements another Cochrane review by the same authors: Intensity of continuous renal replacement therapy for acute kidney injury. OBJECTIVES To assess the effects of different timing (early and standard) of KRT initiation on death and recovery of kidney function in critically ill patients with AKI. SEARCH METHODS We searched the Cochrane Kidney and Transplant's Specialised Register to 4 August 2022 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, EMBASE, conference proceedings, the International Clinical Trials Register, ClinicalTrials and LILACS to 1 August 2022. SELECTION CRITERIA We included all randomised controlled trials (RCTs). We included all patients with AKI in the ICU regardless of age, comparing early versus standard KRT initiation. For safety and cost outcomes, we planned to include cohort studies and non-RCTs. DATA COLLECTION AND ANALYSIS Data were extracted independently by two authors. The random-effects model was used, and results were reported as risk ratios(RR) for dichotomous outcomes and mean difference(MD) for continuous outcomes, with 95% confidence intervals (CI). MAIN RESULTS We included 12 studies enrolling 4880 participants. Overall, most domains were assessed as being at low or unclear risk of bias. Compared to standard treatment, early KRT initiation may have little to no difference on the risk of death at day 30 (12 studies, 4826 participants: RR 0.97,95% CI 0.87 to 1.09; I²= 29%; low certainty evidence), and death after 30 days (7 studies, 4534 participants: RR 0.99, 95% CI 0.92 to 1.07; I² = 6%; moderate certainty evidence). Early KRT initiation may make little or no difference to the risk of death or non-recovery of kidney function at 90 days (6 studies, 4011 participants: RR 0.91, 95% CI 0.74 to 1.11; I² = 66%; low certainty evidence); CIs included both benefits and harms. Low certainty evidence showed early KRT initiation may make little or no difference to the number of patients who were free from KRT (10 studies, 4717 participants: RR 1.07, 95% CI 0.94 to1.22; I² = 55%) and recovery of kidney function among survivors who were free from KRT after day 30 (10 studies, 2510 participants: RR 1.02, 95% CI 0.97 to 1.07; I² = 69%) compared to standard treatment. High certainty evidence showed early KRT initiation increased the risk of hypophosphataemia (1 study, 2927 participants: RR 1.80, 95% CI 1.33 to 2.44), hypotension (5 studies, 3864 participants: RR 1.54, 95% CI 1.29 to 1.85; I² = 0%), cardiac-rhythm disorder (6 studies, 4483 participants: RR 1.35, 95% CI 1.04 to 1.75; I² = 16%), and infection (5 studies, 4252 participants: RR 1.33, 95% CI 1.00 to 1.77; I² = 0%); however, it is uncertain whether early KRT initiation increases or reduces the number of patients who experienced any adverse events (5 studies, 3983 participants: RR 1.23, 95% CI 0.90 to 1.68; I² = 91%; very low certainty evidence). Moderate certainty evidence showed early KRT initiation probably reduces the number of days in hospital (7 studies, 4589 participants: MD-2.45 days, 95% CI -4.75 to -0.14; I² = 10%) and length of stay in ICU (5 studies, 4240 participants: MD -1.01 days, 95% CI -1.60 to -0.42; I² = 0%). AUTHORS' CONCLUSIONS Based on mainly low to moderate certainty of the evidence, early KRT has no beneficial effect on death and may increase the recovery of kidney function. Earlier KRT probably reduces the length of ICU and hospital stay but increases the risk of adverse events. Further adequate-powered RCTs using robust and validated tools that complement clinical judgement are needed to define the optimal time of KRT in critical patients with AKI in order to improve their outcomes. The surgical AKI population should be considered in future research.
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Affiliation(s)
- Alicia Isabel Fayad
- Pediatric Nephrology, Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina
| | - Daniel G Buamscha
- Pediatric Critical Care Unit, Juan Garrahan Children's Hospital, Buenos Aires, Argentina
| | - Agustín Ciapponi
- Argentine Cochrane Centre, Institute for Clinical Effectiveness and Health Policy (IECS-CONICET), Buenos Aires, Argentina
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Grolleau F, Porcher R, Barbar S, Hajage D, Bourredjem A, Quenot JP, Dreyfuss D, Gaudry S. Personalization of renal replacement therapy initiation: a secondary analysis of the AKIKI and IDEAL-ICU trials. Crit Care 2022; 26:64. [PMID: 35313942 PMCID: PMC8939225 DOI: 10.1186/s13054-022-03936-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2022] [Accepted: 02/22/2022] [Indexed: 11/10/2022] Open
Abstract
Background Trials comparing early and delayed strategies of renal replacement therapy in patients with severe acute kidney injury may have missed differences in survival as a result of mixing together patients at heterogeneous levels of risks. Our aim was to evaluate the heterogeneity of treatment effect on 60-day mortality from an early vs a delayed strategy across levels of risk for renal replacement therapy initiation under a delayed strategy. Methods We used data from the AKIKI, and IDEAL-ICU randomized controlled trials to develop a multivariable logistic regression model for renal replacement therapy initiation within 48 h after allocation to a delayed strategy. We then used an interaction with spline terms in a Cox model to estimate treatment effects across the predicted risks of RRT initiation. Results We analyzed data from 1107 patients (619 and 488 in the AKIKI and IDEAL-ICU trial respectively). In the pooled sample, we found evidence for heterogeneous treatment effects (P = 0.023). Patients at an intermediate-high risk of renal replacement therapy initiation within 48 h may have benefited from an early strategy (absolute risk difference, − 14%; 95% confidence interval, − 27% to − 1%). For other patients, we found no evidence of benefit from an early strategy of renal replacement therapy initiation but a trend for harm (absolute risk difference, 8%; 95% confidence interval, − 5% to 21% in patients at intermediate-low risk). Conclusions We have identified a clinically sound heterogeneity of treatment effect of an early vs a delayed strategy of renal replacement therapy initiation that may reflect varying degrees of kidney demand-capacity mismatch. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03936-y.
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Affiliation(s)
- François Grolleau
- Centre of Research in Epidemiology and Statistics (CRESS), Université de Paris, French Institute of Health and Medical Research (INSERM U1153), French National Research Institute for Agriculture, Food, and Environment (INRAE), Paris, France.
| | - Raphaël Porcher
- Centre of Research in Epidemiology and Statistics (CRESS), Université de Paris, French Institute of Health and Medical Research (INSERM U1153), French National Research Institute for Agriculture, Food, and Environment (INRAE), Paris, France
| | - Saber Barbar
- Intensive Care Department, Nîmes University Hospital, University of Montpellier, Nîmes, France
| | - David Hajage
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Hôpital Pitié-Salpêtrière, Département de Santé Publique, Centre de Pharmacoépidémiologie, Sorbonne Université, Paris, France
| | - Abderrahmane Bourredjem
- Clinical Epidemiology Unit, INSERM CIC1432, Dijon, and Clinical Investigation Center, Clinical Epidemiology/Clinical Trials Unit, Dijon Bourgogne University Hospital, Dijon, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Lipness Team, INSERM Research Center, LNC-UMR1231 and LabEx LipSTIC, and INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Didier Dreyfuss
- Université de Paris, Service de Médecine Intensive-Réanimation, Hôpital Louis Mourier, AP-HP and INSERM, UMR S1155 "Common and Rare Kidney Diseases: From Molecular Events To Precision Medicine", Sorbonne Université, Paris, France
| | - Stéphane Gaudry
- Service de Réanimation Médico-Chirurgicale, Hôpital Avicenne, APHP, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, French National Institute of Health and Medical Research (INSERM), Common and Rare kidney Diseases (CORAKID), Hôpital Tenon, Paris, France
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3
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Xiao C, Xiao J, Cheng Y, Li Q, Li W, He T, Li S, Gao D, Shen F. The Efficacy and Safety of Early Renal Replacement Therapy in Critically Ill Patients With Acute Kidney Injury: A Meta-Analysis With Trial Sequential Analysis of Randomized Controlled Trials. Front Med (Lausanne) 2022; 9:820624. [PMID: 35265638 PMCID: PMC8898954 DOI: 10.3389/fmed.2022.820624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Accepted: 01/11/2022] [Indexed: 11/13/2022] Open
Abstract
The efficacy and safety of early renal replacement therapy (eRRT) for critically ill patients with acute kidney injury (AKI) remain controversial. Therefore, the purpose of our study was to perform an up-to-date meta-analysis with the trial sequential analysis (TSA) of randomized controlled trials (RCTs) to evaluate the therapeutic effect of eRRT on patients in an intensive care unit (ICU). We extensively searched MEDLINE, EMBASE, LILACS, the Cochrane Central Register of Controlled Trials and ClinicalTrials.gov, Gray Literature Report, and Bielefeld Academic Search Engine (BASE), and conducted an updated search on December 27, 2021. The included studies were RCTs, which compared the efficacy and safety of eRRT and delayed renal replacement therapy (dRRT) on critically ill patients with AKI. We adopted TSA and sensitivity analysis to strengthen the robustness of the results. About 12 RCTs with a total of 5,423 participants were included. Patients receiving eRRT and dRRT had the similar rate of all-cause mortality at day 28 (38.7% vs. 38.9%) [risk ratio (RR), 1.00; 95%CI, 0.93-1.07, p = 0.93, I 2 = 0%, p = 0.93]. A sensitivity and subgroup analysis produced similar results for the primary outcome. TSA showed that the required information size was 5,034, and the cumulative Z-curve crossed trial sequential monitoring boundaries for futility. Patients receiving eRRT had a higher rate of renal replacement therapy (RRT) (RR, 1.50, 95% CI: 1.28-1.76, p < 0.00001, I 2 = 96%), and experienced more adverse events comparing to those receiving dRRT (RR: 1.41, 95% CI: 1.22-1.63, p < 0.0001, heterogeneity not applied). The most remarkable and important experimental finding is that, to our knowledge, the current meta-analysis included the largest sample size from the RCTs, which were published in the past 10 years to date, show that eRRT had no significant survival benefit for ill patients with AKI compared with dRRT and TSA indicating that no more studies were needed to confirm it. Trial Registration INPLASY, INPLASY2020120030. Registered 04 December 2020.
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Affiliation(s)
- Chuan Xiao
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, China.,School of Clinical Medicine, Guizhou Medical University, Guiyang, China
| | - Jingjing Xiao
- School of Clinical Medicine, Guizhou Medical University, Guiyang, China
| | - Yumei Cheng
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, China.,School of Clinical Medicine, Guizhou Medical University, Guiyang, China
| | - Qing Li
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, China.,School of Clinical Medicine, Guizhou Medical University, Guiyang, China
| | - Wei Li
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, China.,School of Clinical Medicine, Guizhou Medical University, Guiyang, China
| | - Tianhui He
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, China.,School of Clinical Medicine, Guizhou Medical University, Guiyang, China
| | - Shuwen Li
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, China.,School of Clinical Medicine, Guizhou Medical University, Guiyang, China
| | - Daixiu Gao
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, China.,School of Clinical Medicine, Guizhou Medical University, Guiyang, China
| | - Feng Shen
- Department of Intensive Care Unit, The Affiliated Hospital of Guizhou Medical University, Guiyang, China.,School of Clinical Medicine, Guizhou Medical University, Guiyang, China
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Chen J, Huang X, Lin Z, Li C, Ding H, Du J, Li L. Case Report: Monitoring Vancomycin Concentrations and Pharmacokinetic Parameters in Continuous Veno-Venous Hemofiltration Patients to Guide Individualized Dosage Regimens: A Case Analysis. Front Pharmacol 2021; 12:763575. [PMID: 34955835 PMCID: PMC8695924 DOI: 10.3389/fphar.2021.763575] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
There are limited pharmacokinetic (PK) studies on vancomycin in patients treated with continuous renal replacement therapy (CRRT), and the results have been inconsistent. Because of individual differences, proposing a definite recommendation for the clinical regimen is not possible. Rapidly reaching target vancomycin concentrations will facilitate effective treatment for critically ill patients treated with CRRT. In this study, to understand the dynamic change in drug clearance rates in vivo, analyze the effect of PK changes on drug concentrations, and recommend loading and maintenance dosage regimens, we monitored the blood concentrations of vancomycin and calculated the area under the curve in two critically ill patients treated with vancomycin and continuous veno-venous hemofiltration (CVVH). On the basis of real-time therapeutic drug monitoring results and PK parameters, an individualized vancomycin regimen was developed for patients with CVVH. Good clinical efficacy was achieved, which provided support and reference for empirical vancomycin therapy in these patients.
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Affiliation(s)
- Jihui Chen
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Xiaohui Huang
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhiyan Lin
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Chao Li
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Haoshu Ding
- Department of Anesthesiology and SICU, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Junming Du
- Department of Anesthesiology and SICU, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Lixia Li
- Department of Pharmacy, Xinhua Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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5
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An JN, Kim SG, Song YR. When and why to start continuous renal replacement therapy in critically ill patients with acute kidney injury. Kidney Res Clin Pract 2021; 40:566-577. [PMID: 34781642 PMCID: PMC8685358 DOI: 10.23876/j.krcp.21.043] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2021] [Accepted: 07/22/2021] [Indexed: 01/20/2023] Open
Abstract
Acute kidney injury (AKI) is a common condition in critically ill patients, and may contribute to significant medical, social, and economic consequences, including death. Although there have been advances in medical technology, including continuous renal replacement therapy (CRRT), the mortality rate of AKI is high, and there is no fundamental treatment that can reverse disease progression. The decision to implement CRRT is often subjective and based primarily on the clinician’s judgment without consistent and concrete guidelines or protocols regarding when to initiate and discontinue CRRT and how to manage complications. Recently, several randomized controlled trials addressing the initiation of renal replacement therapy in critically ill patients with AKI have been completed, but clinical application of the findings is limited by the heterogeneity of the objectives and research designs. In this review, the advantages and disadvantages of CRRT initiation, clinical guideline recommendations, and the results of currently published clinical trials and meta-analyses are summarized to guide patient care and identify future research priorities.
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Affiliation(s)
- Jung Nam An
- Division of Nephrology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Sung Gyun Kim
- Division of Nephrology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea.,Hallym University Kidney Research Institute, Anyang, Republic of Korea
| | - Young Rim Song
- Division of Nephrology, Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea.,Hallym University Kidney Research Institute, Anyang, Republic of Korea.,Department of Biomedical Gerontology, Graduate School of Hallym University, Chuncheon, Korea
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6
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Van De Ginste L, Vanommeslaeghe F, Hoste EAJ, Kruse JM, Van Biesen W, Verbeke F. Patients with Severe Lactic Acidosis in the Intensive Care Unit: A Retrospective Study of Contributing Factors and Impact of Renal Replacement Therapy. Blood Purif 2021; 51:577-583. [PMID: 34525474 DOI: 10.1159/000518918] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Accepted: 08/04/2021] [Indexed: 11/19/2022]
Abstract
INTRODUCTION Hyperlactatemia is a regular condition in the intensive care unit, which is often associated with adverse outcomes. Control of the triggering condition is the most effective treatment of hyperlactatemia, but since this is mostly not readily possible, extracorporeal renal replacement therapy (RRT) is often tried as a last resort. The present study aims to evaluate the factors that may contribute to the decision whether to start RRT or not and the potential impact of the start of RRT on the outcome in patients with severe lactic acidosis (SLA) (lactate ≥5 mmol/L). MATERIALS AND METHODS We conducted a retrospective single-center cohort analysis over a 3-year period including all patients with a lactate level ≥5 mmol/L. Patients were considered as treated with RRT because of SLA if RRT was started within 24 h after reaching a lactate level ≥5 mmol/L. RESULTS Overall, 90-day mortality in patients with SLA was 34.5%. Of the 1,203 patients who matched inclusion/exclusion criteria, 11% (n = 133) were dialyzed within 24 h. The propensity to receive RRT was related to the lactate level and to the SOFA renal and cardio score. The most frequently used modality was continuous RRT. Patients who were started on RRT versus those who did not have 2.3 higher odds of mortality, even after adjustment for the propensity to start RRT. CONCLUSIONS Our analysis confirms the high mortality rate of patients with SLA. It adds that odds for mortality is even higher in patients who were started on RRT versus not. We suggest keeping an open mind to the factors that may influence the decision to start dialysis and bear in mind that without being a bridge to correction of the underlying condition, dialysis is unlikely to affect the outcome.
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Affiliation(s)
| | | | - Eric A J Hoste
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Jan M Kruse
- Department of Nephrology and Medical Intensive Care, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Wim Van Biesen
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium
| | - Francis Verbeke
- Department of Nephrology, Ghent University Hospital, Ghent, Belgium
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7
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Bhatt GC, Das RR, Satapathy A. Early versus Late Initiation of Renal Replacement Therapy: Have We Reached the Consensus? An Updated Meta-Analysis. Nephron Clin Pract 2021; 145:371-385. [PMID: 33915551 DOI: 10.1159/000515129] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2020] [Accepted: 02/05/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES The objective of this study is to compare early versus late/standard initiation of renal replacement therapy (RRT) in patients with acute kidney injury (AKI). DATA SOURCES MEDLINE/PubMed, Embase, Google Scholar, Cochrane Central Register of Controlled Trials, and the Cochrane renal group till August 15, 2020. STUDY SELECTION Randomized controlled trials (RCTs) comparing early versus late initiation of RRT in patients with AKI were included. The primary outcome measures were all-cause mortality and dialysis dependence on day 90. Secondary outcome measures were length of stay, recovery of renal functions, and adverse events. DATA EXTRACTION Two authors independently performed study selection and data extraction using data extraction forms. DATA SYNTHESIS A total of 14 RCTs with 5,234 participants were included. Three trials had low risk of bias in all the domains. There was no significant difference in the overall mortality (risk ratio (RR): 0.99; 95% confidence interval (CI): 0.89, 1.10; moderate certainty of evidence), day 30 mortality (RR: 1.0; 95% CI: 0.91, 1.09; high certainty of evidence), day 90 mortality (RR: 1.00; 95% CI: 0.88, 1.13; high certainty of evidence), and ICU mortality (RR: 1.00; 95% CI: 0.90, 1.10; moderate certainty of evidence) between the early versus late RRT. Dialysis dependence on day 90 was significantly higher in the patients assigned to early RRT (RR: 1.55; 95% CI: 1.15, 2.09; moderate certainty of evidence). The treatment-emergent adverse events (hypophosphatemia and hypotension) were significantly higher in the patients assigned to early RRT. CONCLUSION There is no added benefit of early initiation of RRT in patient with AKI; this may lead to treatment-emergent adverse events. Delaying the initiation of RRT with close monitoring and initiating RRT for emergent indications should be the acceptable criterion in critical care nephrology. Prospero Registration: CRD42016043092.
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Affiliation(s)
- Girish C Bhatt
- Department of Pediatrics, ISN-SRC, Pediatric Nephrology, AIIMS, Bhopal, India
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8
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Qu G, Chen F, Xu Q, He Z. Timing of continuous renal replacement therapy in patients with acute non-ST-segment elevation myocardial infarction complicated with cardiac and renal insufficiency. Am J Transl Res 2021; 13:3418-3426. [PMID: 34017517 PMCID: PMC8129374] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2020] [Accepted: 01/07/2021] [Indexed: 06/12/2023]
Abstract
OBJECTIVE To explore the efficacy of different timing options for continuous renal replacement therapy (CRRT) in patients with acute non-ST-segment elevation myocardial infarction (NSTEMI) and cardiac and renal insufficiency. METHODS Eighty-eight patients with acute NSTEMI complicated with cardiac and renal insufficiency received PCI treatment after achieving a stable condition and were randomly divided into the control group (n = 44) and the research group (n = 44). The control group was given CRRT after percutaneous coronary intervention (PCI), and the research group was treated with CRRT before and after PCI. The clinical treatment efficacy, cardiac function indexes (left ventricular ejection fraction (LVEF), cardiac output (CO), and left ventricular end diastolic diameter (LVEDD)), renal function indexes (creatinine (Cr), glomerular filtration rate (GFR), neutrophil gelatinase-associated lipocalin (NGAL)), quality of life (QoL) and incidence of major adverse cardiovascular events were compared between the two groups. RESULTS After treatment, the overall effective rate in the research group was higher than that in the control group (P < 0.05); LVEF, CO, GFR and QoL score were higher, while LVEDD value, creatinine level, NGAL level and the incidence of major adverse cardiovascular events were lower in the research group than in the control group (P < 0.05). CONCLUSION For patients with acute NSTEMI complicated with cardiac and renal insufficiency, the use of CRRT before and after PCI can effectively ameliorate cardiac and renal function, and significantly improve quality of life with a good prognosis.
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Affiliation(s)
- Guomei Qu
- Department of Hemodialysis Center, The First Affiliated Hospital of Soochow UniversitySuzhou, Jiangsu Province, China
| | - Fengling Chen
- Department of Hemodialysis Center, The First Affiliated Hospital of Soochow UniversitySuzhou, Jiangsu Province, China
| | - Qinjuan Xu
- Department of Hemodialysis Center, The First Affiliated Hospital of Soochow UniversitySuzhou, Jiangsu Province, China
| | - Zhisong He
- Department of Cardiology, The First Affiliated Hospital of Soochow UniversitySuzhou, Jiangsu Province, China
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9
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Andonovic M, Shemilt R, Sim M, Traynor JP, Shaw M, Mark PB, Puxty KA. Timing of renal replacement therapy for patients with acute kidney injury: A systematic review and meta-analysis. J Intensive Care Soc 2021; 22:67-77. [PMID: 33643435 PMCID: PMC7890756 DOI: 10.1177/1751143720901688] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Acute kidney injury is associated with high mortality, and the optimal time to start renal replacement therapy for acute kidney injury is unknown despite several randomised controlled trials on the subject. We performed a systematic review and meta-analysis to assess the effect of earlier initiation of renal replacement therapy for acute kidney injury on mortality and reported secondary outcomes. METHODS All literature in databases EMBASE, MEDLINE and CENTRAL was searched from January 1970 to March 2019 using terms related to renal replacement therapy, timing and randomised controlled trials. All randomised controlled trials with 25 or more adult participants suffering from acute kidney injury comparing timing of renal replacement therapy were included. The results of the selected studies were pooled and expressed in terms of risk ratios (RR) and 95% confidence intervals (95% CI) using a random effects model. RESULTS A total of 7008 records were identified; 94 were selected for full text review of which 10 were included in the final meta-analysis. The 10 studies comprised 1956 participants (989 'early' group; 967 'late' group) with 918 total deaths; the analysis demonstrated no significant differences between the 'early' and 'late' renal replacement therapy groups (RR = 0.98 (95% CI = 0.84, 1.15)) for mortality. No significant differences between groups were evident for period-wise mortality; dialysis dependence; recovery of renal function; length of intensive care unit or hospital stay; or number of renal replacement therapies, mechanical ventilation and vasopressor-free days. CONCLUSIONS Current evidence does not support the use of early renal replacement therapy for patients with acute kidney injury. Data from ongoing and future randomised controlled trials are required to strengthen the evidence base in the area.
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Affiliation(s)
- Mark Andonovic
- Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, UK
| | - Richard Shemilt
- Department of Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Malcolm Sim
- Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, UK
- Department of Intensive Care, Queen Elizabeth University Hospital, Glasgow, UK
| | - Jamie P Traynor
- Department of Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
| | - Martin Shaw
- Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, UK
| | - Patrick B Mark
- Department of Nephrology, Queen Elizabeth University Hospital, Glasgow, UK
- Institute of Cardiovascular and Medical Sciences, University of Glasgow, Glasgow, UK
| | - Kathryn A Puxty
- Academic Unit of Anaesthesia, Pain and Critical Care, University of Glasgow, Glasgow, UK
- Department of Intensive Care Medicine, Glasgow Royal Infirmary, Glasgow, UK
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10
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Yang Y, Shi J, Ge S, Guo S, Xing X, Wang Y, Cheng A, Liu Q, Li J, Ning Y, He F, Xu G. Association between Prolonged Intermittent Renal Replacement Therapy and All-Cause Mortality in COVID-19 Patients Undergoing Invasive Mechanical Ventilation: A Retrospective Cohort Study. Blood Purif 2020; 50:481-488. [PMID: 33271549 PMCID: PMC7801996 DOI: 10.1159/000512099] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 10/02/2020] [Indexed: 12/01/2022]
Abstract
Background The mortality rate of critically ill patients with coronavirus disease 2019 (COVID-19) was high. We aimed to assess the association between prolonged intermittent renal replacement therapy (PIRRT) and mortality in patients with COVID-19 undergoing invasive mechanical ventilation. Methods This retrospective cohort study included all COVID-19 patients receiving invasive mechanical ventilation between February 12 and March 2, 2020. All patients were followed until death or March 28, and all survivors were followed for at least 30 days. Results For 36 hospitalized COVID-19 patients receiving invasive mechanical ventilation, the mean age was 69.4 (±10.8) years, and 30 patients (83.3%) were men. Twenty-two (61.1%) patients received PIRRT (PIRRT group), and 14 cases (38.9%) were managed with conventional strategy (non-PIRRT group). There were no differences in age, sex, comorbidities, complications, treatments, and most of the laboratory findings. During the median follow-up period of 9.5 (interquartile range 4.3–33.5) days, 13 of 22 (59.1%) patients in the PIRRT group and 11 of 14 (78.6%) patients in the non-PIRRT group died. Kaplan-Meier analysis demonstrated prolonged survival in patients in the PIRRT group compared with that in the non-PIRRT group (p = 0.042). The association between PIRRT and a reduced risk of mortality remained significant in 3 different models, with adjusted hazard ratios varying from 0.332 to 0.398. Increased IL–2 receptor, TNF-α, procalcitonin, prothrombin time, and NT-proBNP levels were significantly associated with an increased risk of mortality in patients with PIRRT. Conclusion PIRRT may be beneficial for the treatment of COVID-19 patients with invasive mechanical ventilation. Further prospective multicenter studies with larger sample sizes are required.
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Affiliation(s)
- Yi Yang
- Department of Nephrology, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia Shi
- Department of Nephrology, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuwang Ge
- Department of Nephrology, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Shuiming Guo
- Department of Nephrology, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xue Xing
- Department of Nephrology, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yanan Wang
- Department of Nephrology, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Anying Cheng
- Department of Nephrology, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Qingquan Liu
- Department of Nephrology, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Junhua Li
- Department of Nephrology, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yong Ning
- Department of Nephrology, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fan He
- Department of Nephrology, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China,
| | - Gang Xu
- Department of Nephrology, Tongji Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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Abarca Rozas B, Mestas Rodríguez M, Widerström Isea J, Lobos Pareja B, Vargas Urra J. A current view on the early diagnosis and treatment of acute kidney failure. Medwave 2020; 20:e7928. [DOI: 10.5867/medwave.2020.05.7928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2019] [Accepted: 05/18/2020] [Indexed: 11/27/2022] Open
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12
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Karkar A, Ronco C. Prescription of CRRT: a pathway to optimize therapy. Ann Intensive Care 2020; 10:32. [PMID: 32144519 PMCID: PMC7060300 DOI: 10.1186/s13613-020-0648-y] [Citation(s) in RCA: 72] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2020] [Accepted: 02/26/2020] [Indexed: 12/21/2022] Open
Abstract
Severe acute kidney injury (AKI), especially when caused or accompanied by sepsis, is associated with prolonged hospitalization, progression to chronic kidney disease (CKD), financial burden, and high mortality rate. Continuous renal replacement therapy (CRRT) is a predominant form of renal replacement therapy (RRT) in the intensive care unit (ICU) due to its accurate volume control, steady acid-base and electrolyte correction, and achievement of hemodynamic stability. This manuscript reviews the different aspects of CRRT prescription in critically ill patients with severe AKI, sepsis, and multiorgan failure in ICU. These include the choice of CRRT versus Intermittent and extended hemodialysis (HD), life of the filter/dialyzer including assessment of filtration fraction, anticoagulation including regional citrate anticoagulation (RCA), prescribed versus delivered CRRT dose, vascular access management, timing of initiation and termination of CRRT, and prescription in AKI/sepsis including adsorptive methods of removing endotoxins and cytokines.
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Affiliation(s)
- Ayman Karkar
- Medical Affairs-Renal Care, Scientific Office, Baxter A.G., Burj Al Salam, PO Box 64332, Dubai, United Arab Emirates.
- Department of Nephrology Dialysis and Transplantation, International Renal Research Institute of Vicenza, San Bortolo Hospital, Vicenza, Italy.
| | - Claudio Ronco
- Medical Affairs-Renal Care, Scientific Office, Baxter A.G., Burj Al Salam, PO Box 64332, Dubai, United Arab Emirates
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13
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Chen JJ, Lee CC, Kuo G, Fan PC, Lin CY, Chang SW, Tian YC, Chen YC, Chang CH. Comparison between watchful waiting strategy and early initiation of renal replacement therapy in the critically ill acute kidney injury population: an updated systematic review and meta-analysis. Ann Intensive Care 2020; 10:30. [PMID: 32128633 PMCID: PMC7054512 DOI: 10.1186/s13613-020-0641-5] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2019] [Accepted: 02/18/2020] [Indexed: 12/18/2022] Open
Abstract
Background The optimal timing of renal replacement therapy (RRT) initiation is debatable. Many articles in this field enrolled trials not based on acute kidney injury. The safety of the watchful waiting strategy has not been fully discussed, and late RRT initiation criteria vary across studies. The effect of early RRT initiation in the AKI population with high plasma neutrophil gelatinase-associated lipocalin (NGAL) has not been examined yet. Methods In accordance with PRISMA guidelines, the PubMed, Embase, and Cochrane databases were systemically searched for randomized controlled trials (RCTs). Trials not conducted in the AKI population were excluded. Data of study characteristics, primary outcome (all-cause mortality), and related secondary outcomes [mechanical ventilation (MV) days, length of hospital stay, RRT days, and length of ICU stay] were extracted. The outcomes were compared between early and late RRT groups by estimating the pooled odds ratio (OR) for binary outcomes and the weighted mean difference for continuous outcomes. Prospective trials were also examined and analyzed using the same method. Results Nine RCTs with 1938 patients were included. Early RRT did not provide a survival benefit (pooled OR, 0.88; 95% confidence interval [CI] 0.62–1.27). However, the early RRT group had significantly fewer MV days (pooled mean difference, − 3.98 days; 95% CI − 7.81 to − 0.15 days). Subgroup analysis showed that RCTs enrolling the surgical population (P = .001) and the AKI population with high plasma NGAL (P = .031) had favorable outcomes regarding RRT days in the early initiation group. Moreover, 6 of 9 RCTs were selected for examining the safety of the watchful waiting strategy, and no significant differences were found in primary and secondary outcomes between the early and late RRT groups. Conclusions Overall, early RRT initiation did not provide a survival benefit, but a possible benefit of fewer MV days was detected. Early RRT might also provide the benefit of shorter MV or RRT support in the surgical population and in AKI patients with high plasma NGAL. Depending on the conventional indication for RRT initiation, the watchful waiting strategy is safe on the basis of all primary and secondary outcomes.
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Affiliation(s)
- Jia-Jin Chen
- Department of Nephrology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Cheng-Chia Lee
- Department of Nephrology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, No 5 Fu-shin Street, Taoyuan, 333, Taiwan
| | - George Kuo
- Department of Nephrology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Pei-Chun Fan
- Department of Nephrology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, No 5 Fu-shin Street, Taoyuan, 333, Taiwan
| | - Chan-Yu Lin
- Department of Nephrology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, No 5 Fu-shin Street, Taoyuan, 333, Taiwan
| | - Su-Wei Chang
- Clinical Informatics and Medical Statistics Research Center, College of Medicine, Chang Gung University, Taoyuan, Taiwan
| | - Ya-Chung Tian
- Department of Nephrology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan.,Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, No 5 Fu-shin Street, Taoyuan, 333, Taiwan
| | - Yung-Chang Chen
- Division of Critical Care Nephrology, Department of Nephrology, Chang Gung Memorial Hospital, Keelung, Taiwan
| | - Chih-Hsiang Chang
- Department of Nephrology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan. .,Department of Nephrology, Kidney Research Center, Linkou Chang Gung Memorial Hospital, No 5 Fu-shin Street, Taoyuan, 333, Taiwan.
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