1
|
Gaudry S, Hajage D, Martin-Lefevre L, Louis G, Moschietto S, Titeca-Beauport D, La Combe B, Pons B, de Prost N, Besset S, Combes A, Robine A, Beuzelin M, Badie J, Chevrel G, Reignier J, Bohé J, Coupez E, Chudeau N, Barbar S, Vinsonneau C, Forel JM, Thevenin D, Boulet E, Lakhal K, Aissaoui N, Grange S, Leone M, Lacave G, Nseir S, Poirson F, Mayaux J, Asehnoune K, Geri G, Klouche K, Thiery G, Argaud L, Ricard JD, Quenot JP, Dreyfuss D. The Artificial Kidney Initiation in Kidney Injury 2 (AKIKI2): study protocol for a randomized controlled trial. Trials 2019; 20:726. [PMID: 31843007 PMCID: PMC6915917 DOI: 10.1186/s13063-019-3774-9] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 10/09/2019] [Indexed: 01/09/2023] Open
Abstract
BACKGROUND The Artificial Kidney Initiation in Kidney Injury (AKIKI) trial showed that a delayed renal replacement therapy (RRT) strategy for severe acute kidney injury (AKI) in critically ill patients was safe and associated with major reduction in RRT initiation compared with an early strategy. The five criteria which mandated RRT initiation in the delayed arm were: severe hyperkalemia, severe acidosis, acute pulmonary edema due to fluid overload resulting in severe hypoxemia, serum urea concentration > 40 mmol/l and oliguria/anuria > 72 h. However, duration of anuria/oliguria and level of blood urea are still criteria open to debate. The objective of the study is to compare the delayed strategy used in AKIKI (now termed "standard") with another in which RRT is further delayed for a longer period (termed "delayed strategy"). METHODS/DESIGN This is a prospective, multicenter, open-label, two-arm randomized trial. The study is composed of two stages (observational and randomization stages). At any time, the occurrence of a potentially severe condition (severe hyperkalemia, severe metabolic or mixed acidosis, acute pulmonary edema due to fluid overload resulting in severe hypoxemia) suggests immediate RRT initiation. Patients receiving (or who have received) intravenously administered catecholamines and/or invasive mechanical ventilation and presenting with AKI stage 3 of the KDIGO classification and with no potentially severe condition are included in the observational stage. Patients presenting a serum urea concentration > 40 mmol/l and/or an oliguria/anuria for more than 72 h are randomly allocated to a standard (RRT is initiated within 12 h) or a delayed RRT strategy (RRT is initiated only if an above-mentioned potentially severe condition occurs or if the serum urea concentration reaches 50 mmol/l). The primary outcome will be the number of RRT-free days at day 28. One interim analysis is planned. It is expected to include 810 patients in the observational stage and to randomize 270 subjects. DISCUSSION The AKIKI2 study should improve the knowledge of RRT initiation criteria in critically ill patients. The potential reduction in RRT use allowed by a delayed RRT strategy might be associated with less invasive care and decreased costs. Enrollment is ongoing. Inclusions are expected to be completed by November 2019. TRIAL REGISTRATION ClinicalTrials.gov, ID: NCT03396757. Registered on 11 January 2018.
Collapse
Affiliation(s)
- Stéphane Gaudry
- French National Institute of Health and Medical Research (INSERM), UMR_S1155, Remodeling and Repair of Renal Tissue, Hôpital Tenon, Sorbonne Université, F-75020 Paris, France
- AP-HP, Hôpital Avicenne, Service de Réanimation Médico-Chirurgicale, 125 Rue de Stalingrad, 93000 Bobigny, France
- Health Care Simulation Center, UFR SMBH, Université Paris 13, Sorbonne Paris Cité, Bobigny, France
| | - David Hajage
- AP-HP, Hôpitaux Universitaires Pitié Salpêtrière-Charles Foix, Département Biostatistique Santé Publique et Information Médicale, Centre de Pharmacoépidémiologie (Cephepi), Sorbonne Université, INSERM, Institut Pierre Louis d’Epidémiologie et de Santé Publique, CIC-1421, F75013 Paris, France
| | - Laurent Martin-Lefevre
- Réanimation polyvalente, CHR départementale La Roche Sur Yon, 85025 La Roche Sur Yon, France
| | - Guillaume Louis
- Réanimation polyvalente, CHR Metz-Thionville Hôpital de Mercy, 57085 Metz, France
| | | | | | | | - Bertrand Pons
- Réanimation, CHU Pointe-a-Pitre/Abymes, 97159 Pointe-a-Pitre, France
| | - Nicolas de Prost
- Réanimation médicale, Hôpital Henri Mondor, 94010 Créteil, France
| | - Sébastien Besset
- Service de Réanimation Médico-Chirurgicale, AP-HP, Hôpital Louis Mourier, 178 rue des Renouillers, F-92700 Colombes, France
| | - Alain Combes
- Service de Réanimation Médicale, AP-HP, Hôpital Pitié Salpêtrière, 75013 Paris, France
| | - Adrien Robine
- Réanimation Soins continus, CH de Bourg-en-Bresse – Fleyriat, 01012 Bourg-en-Bresse, France
| | | | - Julio Badie
- Réanimation polyvalente, Hôpital Nord Franche-Comte CH Belfort, 90016 Belfort, France
| | - Guillaume Chevrel
- Réanimation polyvalente, CH Sud Francilien, 91106 Corbeil Essones, France
| | - Jean Reignier
- Réanimation médicale, Hôtel Dieu, 44035 Nantes, France
| | - Julien Bohé
- Anesthésie réanimation médicale et chirurgicale, CH Lyon Sud, 69495 Pierre Benite,, France
| | - Elisabeth Coupez
- Réanimation polyvalente, Hôpital G. Montpied, 63003 Clermont Ferrand, France
| | - Nicolas Chudeau
- Réanimation médico-chirurgicale, CH du Mans, 72037 Le Mans, France
| | - Saber Barbar
- Réanimation, Hôpital Caremeau, 30029 Nimes, France
| | | | | | | | - Eric Boulet
- Réanimation et USC, GH Carnelle Portes de l’Oise, 95260 Beaumont sur Oise, France
| | - Karim Lakhal
- Anesthésie Réanimation, hôpital Nord laennec, 44093 Nantes, France
| | - Nadia Aissaoui
- Réanimation médicale, Hôpital Georges Pompidou, 75014 Paris, France
| | - Steven Grange
- Réanimation médicale, CHU Rouen, 76031 Rouen, France
| | - Marc Leone
- Anesthésie Réanimation, Hôpital Nord, 13015 Marseille, France
| | - Guillaume Lacave
- Réanimation médico-chirurgicale, Hôpital André Mignot, 78000 Versailles, France
| | - Saad Nseir
- Réanimation médicale, CHRU de Lille, Hôpital Roger Salengro, 59037 Lille, France
| | - Florent Poirson
- AP-HP, Hôpital Avicenne, Service de Réanimation Médico-Chirurgicale, 125 Rue de Stalingrad, 93000 Bobigny, France
| | - Julien Mayaux
- Pneumologie et Réanimation médicale, Hôpital Pitié Salpêtrière, 75013 Paris, France
| | | | - Guillaume Geri
- Réanimation médico-chirurgicale, Hôpital Ambroise Paré, 92100 Boulogne-Billancourt, France
| | - Kada Klouche
- Médecine Intensive Réanimation, Hôpital lapeyronnie, 34295 Montpellier, France
| | - Guillaume Thiery
- Réanimation médicale, CHU Saint Etienne, 42270 Saint Priest en Jarez, France
| | - Laurent Argaud
- Réanimation médicale, Hôpital Edouard Herriot, 69437 Lyon, France
| | - Jean-Damien Ricard
- Service de Réanimation Médico-Chirurgicale, AP-HP, Hôpital Louis Mourier, 178 rue des Renouillers, F-92700 Colombes, France
- Univ Paris Diderot, Sorbonne Paris Cité, IAME, UMRS 1137, F-75018 Paris, France
- INSERM, IAME, U1137, F-75018 Paris, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
- Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France
- INSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Didier Dreyfuss
- French National Institute of Health and Medical Research (INSERM), UMR_S1155, Remodeling and Repair of Renal Tissue, Hôpital Tenon, Sorbonne Université, F-75020 Paris, France
- Service de Réanimation Médico-Chirurgicale, AP-HP, Hôpital Louis Mourier, 178 rue des Renouillers, F-92700 Colombes, France
- Sorbonne Paris-Cité, Paris, France
- Present address: Intensive Care Unit, Hôpital Louis Mourier, 178 rue des Renouillers, 92110 Colombes, France
| |
Collapse
|
4
|
Impact of early nutrition and feeding route on outcomes of mechanically ventilated patients with shock: a post hoc marginal structural model study. Intensive Care Med 2015; 41:875-86. [PMID: 25792207 DOI: 10.1007/s00134-015-3730-4] [Citation(s) in RCA: 38] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2014] [Accepted: 03/02/2015] [Indexed: 12/13/2022]
Abstract
PURPOSE Few data are available about optimal nutrition modalities in mechanically ventilated patients with shock. Our objective was to assess associations linking early nutrition (<48 h after intubation), feeding route and calorie intake to mortality and risk of ventilator-associated pneumonia (VAP) in patients with invasive mechanical ventilation (IMV) and shock. METHODS In the prospective OutcomeRea database, we identified adults with IMV >72 h and shock (arterial systolic pressure <90 mmHg) within 48 h after intubation. A marginal structural Cox model was used to create a pseudo-population in which treatment was unconfounded by subject-specific characteristics. RESULTS We included 3,032 patients. Early nutrition was associated with lower day-28 mortality [HR 0.89, 95 % confidence interval (CI) 0.81-0.98, P = 0.01] and day-7 mortality (HR 0.76, CI 0.66-0.87, P < 0.001) but not with lower day-7 to day-28 mortality (HR 1.00, CI 0.89-1.12, P = 0.98). Early nutrition increased VAP risk over the 28 days (HR 1.08, CI 1.00-1.17, P = 0.046) and until day 7 (HR 7.17, CI 6.27-8.19, P < 0.001) but decreased VAP risk from days 7 to 28 (HR 0.85, CI 0.78-0.92, P < 0.001). Compared to parenteral feeding, enteral feeding was associated with a slightly increased VAP risk (HR 1.11, CI 1.00-1.22, P = 0.04) but not with mortality. Neither mortality nor VAP risk differed between early calorie intakes of ≥20 and <20 kcal/kg/day. CONCLUSION In mechanically ventilated patients with shock, early nutrition was associated with reduced mortality. Neither feeding route nor early calorie intake was associated with mortality. Early nutrition and enteral feeding were associated with increased VAP risk.
Collapse
|