Effect of sustained low efficient dialysis versus continuous renal replacement therapy on renal recovery after acute kidney injury in the intensive care unit: A systematic review and meta-analysis

Long-Term Mortality and Health-Related Quality of Life After Continuous Versus Intermittent Renal Replacement Therapy in ICU Survivors: A Secondary Analysis of the Quality of Life After ICU Study

Purpose: We assessed long-term outcomes in intensive care unit (ICU) survivors with acute kidney injury (AKI) submitted to intermittent or continuous renal replacement therapy (RRT) for comparisons between groups. Methods: The multicenter prospective cohort study included 195 adult ICU survivors with an ICU stay >72 h in 10 ICUs that had at least one episode of AKI treated with intermittent RRT (IRRT) or continuous RRT (CRRT) during ICU stay. The main outcomes were mortality and health-related quality of life (HRQoL). Hospital readmissions and physical dependence were also assessed. Results: Regarding RRT, 83 (42.6%) patients received IRRT and 112 (57.4%) received CRRT. Despite the similarity regarding sociodemographic characteristics, pre-ICU state of health and type of admission between groups, the risk of death (23.5% vs 42.7%; P < .001), the prevalence of sepsis (60.7%) and acute respiratory distress syndrome (17%) were higher at ICU admission among CRRT patients. The severity of critical illness was higher among CRRT patients, regarding the need for mechanical ventilation (75.0% vs 50.6%, P = .002) and vasopressors (91.1% vs 63.9%, P < .001). One year after ICU discharge, 67 of 195 ICU survivors died (34.4%) and, after adjustment for confounders, there were no significant differences in mortality when comparing IRRT and CRTT patients (34.9% vs 33.9%; P = .590), on HRQoL in both physical (41.9% vs 42.2%; P = .926) and mental dimensions (57.6% vs 56.6%; P = .340), and on the number of hospital readmissions and physical dependence. Conclusions: Our study suggests that among ICU survivors RRT modality (IRRT vs CRRT) in the ICU does not impact long-term outcomes after ICU discharge.

Experience of Sustained Low-Efficiency Dialysis (SLED) in an Intensive Care Unit of a Quaternary Care Hospital

BACKGROUND

In critically ill patients, sustained low-efficiency dialysis (SLED) has become a viable option for treating acute kidney injury (AKI) instead of continuous renal replacement therapy (CRRT). This study aimed to evaluate clinical outcomes in critically ill patients receiving SLED.

MATERIAL AND METHODS

In our ICU, we performed a retrospective cohort study on hemodynamically unstable patients requiring dialysis in the form of SLED. Demographics, clinical, and biochemical variables were analyzed.

RESULTS

A total of 58 patients were enrolled in the study. The mean age was 48.58 ± 15 with a male-to-female ratio of 3:1. Higher APACHE II score, high international normalized ratio, thrombocytopenia, and septic shock were found to be poor prognostic markers, with an overall observed mortality of 56.9%.

CONCLUSION

SLED can be considered as an alternative to CCRT for selected hemodynamically unstable patients requiring renal replacement therapy.

Is SLED Efficient in Sepsis Associated Acute Kidney Injury: Hope but Hold!!

How to cite this article: Chhallani AA. Is SLED Efficient in Sepsis Associated Acute Kidney Injury: Hope but Hold!! Indian J Crit Care Med 2024;28(1):5-7.

Daily Hemodialysis Helps Critical Nephritic Lupus Patient: A Case Report

Background: Nephritic lupus is the most common and serious complication of systemic lupus erythematosus (SLE) and is associated with a worse prognosis. Hemodialysis is effective in alleviating symptoms and renal involvement in a nephritic lupus patient. Method: A 33-year-old female was diagnosed with SLE in September 2017. She was also diagnosed with diffuse membranous proliferative glomerulonephritis, as confirmed with a kidney biopsy. She complained of gradual onset limb weakness and peripheral edema 3 months before admission. She was treated with 6 cycles of cyclophosphamide and continued with methylprednisolone 16 mg once daily, hydroxychloroquine 200 mg once daily, and myfortic 360 mg twice daily. A day before ICU admission, her creatinine level was increased to 4.6 mg/dl with an estimated GFR of 12 ml/min and her symptoms then worsened into seizures and lung edema. Daily hemodialysis with heparin-free SLEDD was performed. About 2L was extracted for the first 6 hours with Qb 150 ml and Qd 300 ml and was continued until the day after. For the next 4 days, 3L was extracted per day with Qb 200ml and Qd 500 ml. The patients’ hemodynamic status was within normal limits during dialysis period. The condition improved and the patient was transferred to the ward. Discussions: Hemodialysis is a way to solve kidney problems in in nephritic lupus and SLE patients in general. It should not only be employed for mainly kidney problems but could be beneficial in autoimmune patients with conditions such as nephritic lupus. Slowly extracted dialysis type would be a good and inexpensive option to resolve nephritic lupus in compromising lupus patients. Filtration is ensured and solute removal is achieved relatively equivalent to CRRT. Conclusion: Daily hemodialysis could increase renal salvation by providing less creatinine serum and removing accumulated fluids. The SLEDD type could be used for critical nephritic lupus patients with reduced hemodynamic perturbations, minimal anticoagulant, and lower cost.

Sustained low efficiency dialysis is non-inferior to continuous renal replacement therapy in critically ill patients with acute kidney injury: A comparative meta-analysis

BACKGROUND

Critically ill adults with acute kidney injury (AKI) experience considerable morbidity and mortality. This systematic review aimed to compare the effectiveness of continuous renal replacement therapy (CCRT) versus sustained low efficiency dialysis (SLED) for individuals with AKI.

METHODS

We carried out a systematic search of existing databases according to standard methods and random effects models were used to generate the overall estimate. Heterogeneity coefficient was also calculated for each outcome measure.

RESULTS

Eleven studies having 1160 patients with AKI were included in the analyses. Meta-analysis results indicated that there was no statistically significant difference between SLED versus continuous renal replacement therapy (CRRT) in our primary outcomes, like mortality rate (rate ratio [RR] 0.67, 95% confidence interval [CI] 0.44-1.00; P = .05), renal recovery (RR 1.08, 95% CI 0.83-1.42; P = .56), and dialysis dependence (RR = 1.03, 95% CI 0.69-1.53; P = .89). Also, no statistically significant difference was observed for between SLED versus CRRT in the secondary outcomes: that is, length of intensive care unit stay (mean difference -0.16, 95% CI -0.56-0.22; P = .41) and fluid removal rate (mean difference -0.24, 95% CI -0.72-0.24; P = .32). The summary mean difference indicated that there was a significant difference in the serum phosphate clearance among patients treated with SLED and CRRT (mean difference -1.17, 95% CI -1.90 to -0.44, P = .002).

CONCLUSIONS

The analysis indicate that there was no major advantage of using continuous renal replacement compared with sustained low efficiency dialysis in hemodynamically unstable AKI patients. Both modalities are equally safe and effective in treating AKI among critically ill patients.

Acute kidney injury after cardiac surgery: Sustained low efficiency compared to continuous renal replacement therapy

STUDY OBJECTIVE

Sustained low efficiency dialysis (SLED) has been introduced as a mode of renal replacement therapy (RRT) for treating severe cardiac surgery-associated acute kidney injury (CSA-AKI) at some hospitals; SLED is performed using intermittent hemodialysis (IHD) devices but differs from conventional IHD in its duration and intensity. However, there are limited data comparing SLED against more conventional continuous RRT methods. We conducted a retrospective cohort study to compare outcomes of patients with severe CSA-AKI after an institutional transition from continuous RRT to SLED.

DESIGN

Following research ethics approval, we conducted a retrospective cohort study of patients with severe CSA-AKI requiring RRT.

SETTING

Cardiac Intensive Care Unit at the Toronto General Hospital (Toronto, Ontario, Canada) from 1 January 1999 to 31 December 2011.

PATIENTS

351 consecutive patients with severe CSA-AKI requiring RRT after cardiac surgery.

INTERVENTIONS

The RRT mode was continuous RRT before 31 March 2008, and SLED after 1 April 2008.

MEASUREMENTS

The primary outcome was low-cardiac output syndrome (LCOS) and the main secondary outcome was associated costs. Propensity score matched-pairs analyses were used to compare the outcomes of patients in the continuous RRT period versus the SLED period.

MAIN RESULTS

There were 268 patients treated with continuous RRT and 83 patients treated with SLED. The SLED group had a higher weight, higher baseline hemoglobin concentration, and higher prevalence of obstructive lung disease. In propensity score match-pairs analysis (n = 148), the SLED group experienced similar odds of low cardiac output syndrome (odds ratio [OR] 1.06, 95% CI 0.68 to 1.67), death (OR 1.09, 0.94 to 1.28), acute stroke (OR 0.97, 0.83 to 1.13), myocardial infarction (OR 0.92, 0.84 to 1.01). The use of SLED was associated with a reduced cost compared to continuous RRT. The cost differential for 83 treated patients was CAD$130,974 (CAD$178,159.50 vs CAD$309,133.50) in favor of SLED.

CONCLUSIONS

An institutional transition from continuous RRT to SLED, was associated with a significant lower cost with the use of SLED, while maintaining comparable postoperative outcomes in CSA-AKI patients.

Severe methanol poisoning treated with a novel hemodialysis system: a case report, analysis, and review

In May and June 2020, an outbreak of methanol poisoning arose in the southwest United States linked to ingestion of contaminated hand sanitizer imported during the coronavirus disease 2019 pandemic, ultimately resulting in over a dozen hospitalizations and at least four deaths in New Mexico and Arizona. In this report, we describe one of these cases in which profound methanol intoxication was successfully treated with the Tablo® Hemodialysis System, the first reported case of toxic alcohol poisoning treated with this novel device. We carry out a formal regression analysis of the serial methanol levels obtained in this case to conservatively estimate that intermittent hemodialysis with Tablo achieved a clearance of methanol of 239 mL/min (95% confidence interval, 173–305 mL/min), a clearance that is well within the previously published standard of care. We conclude by reviewing both the treatment of toxic alcohol poisoning and the determinants of small molecule clearance with hemodialysis, emphasizing the importance of optimizing the dialytic treatment of intoxications with extended treatment times and the use of high-efficiency dialyzers.

Vancomycin Population Pharmacokinetics in Critically Ill Adults During Sustained Low-Efficiency Dialysis

BACKGROUND

Sustained low-efficiency dialysis (SLED) is a hybrid form of dialysis that is increasingly used in critically ill patients with kidney injury and hemodynamic instability. Antimicrobial dosing for patients receiving SLED is informed by pharmacokinetic studies that describe the drug clearance. Studies available to assist in the dosing of vancomycin in the context of SLED are lacking.

OBJECTIVE

The objective of this prospective observational study was to describe the population pharmacokinetics of vancomycin in critically ill patients receiving SLED, and use simulation studies to propose dosing strategies.

METHODS

Serial serum samples were obtained from 31 critically ill patients prescribed vancomycin while receiving SLED. Vancomycin concentrations were quantified in plasma using a validated liquid chromatography mass spectrometry/mass spectrometry method. A population pharmacokinetic model was developed, and Monte Carlo simulation was used to determine the probability of target attainment at different doses.

RESULTS

From a total of 335 serum samples from 31 patients receiving 52 sessions of SLED therapy, a two-compartment linear model with zero-order input was developed. The mean (standard deviation) clearance of vancomycin on and off SLED was 5.97 (4.04) and 2.40 (1.46) L/h, respectively. Using pharmacodynamic targets for efficacy (area under the concentration-time curve from time zero to 24 h [AUC₂₄]/minimum inhibitory concentration [MIC] ≥ 400) and safety (AUC₂₄ ≥ 700), a loading dose of 2400 mg followed by daily doses of 1600 mg is recommended. Subsequent dosing should be informed by therapeutic drug monitoring of vancomycin levels.

CONCLUSIONS

In critically ill patients receiving SLED, vancomycin clearance is highly variable with a narrow therapeutic window. Empiric dosing is proposed but subsequent dosing should be guided by drug levels.

Renal replacement therapy modality in critically ill patients with acute kidney injury - A network meta-analysis of randomized controlled trials

PURPOSE

This network meta-analysis aims to compare the efficacy and safety of various renal replacement therapy (RRT) modalities in critically ill patients with acute kidney injury (AKI).

MATERIALS AND METHODS

We searched the electronic databases for randomized controlled trials (RCTs) comparing different RRT modalities, including continuous RRT, intermittent RRT, hybrid RRT, and peritoneal dialysis (PD), in critically ill patients with AKI through July 26, 2020. The primary outcomes were renal recovery and short-term mortality. The study protocol was registered with PROSPERO (CRD42020188115).

RESULTS

Twenty-three studies were included. No difference in the renal recovery or short-term mortality was observed among the four RRT modalities (low certainty). The four RRT modalities had similar effects on the incidence of infectious complications (low certainty). PD was associated with less fluid removal volume and lower incidence of hypotension compared with the extracorporeal modalities, yet no difference in the two outcomes was identified among the extracorporeal modalities (very low to moderate certainty).

CONCLUSIONS

No superiority of one particular RRT modality over another in terms of renal recovery and short-term mortality in critically ill patients with AKI. PD exhibited worse fluid removal and better safety in the prevention of hypotension than the extracorporeal modalities.

Levetiracetam pharmacokinetics in critically ill patients undergoing renal replacement therapy

PURPOSE

To determine clearance of levetiracetam in patients requiring continuous renal replacement therapy (CRRT) or sustained low efficiency dialysis (SLED).

MATERIALS AND METHODS

Adult patients with acute kidney injury or end stage renal disease requiring either CRRT or SLED and levetiracetam were eligible for inclusion. Simultaneous arterial, venous, and effluent samples for analysis of levetiracetam concentrations were collected every two hours for up to 6-8 h. Levetiracetam clearance (CL) and half-life (t_1/2) were calculated for each modality.

RESULTS

Eight CRRT patients and 4 SLED patients completed the study: 67% male, mean age 50 ± 13 years, and 83% had AKI. Seven CRRT patients received continuous venovenous hemodiafiltration (CVVHDF) [median pre-replacement rate 700 mL/h (range 500-1000), post-replacement rate 500 mL/h (range 200-1000), effluent rate 2500 mL/h (range 1700-3650) and delivered CRRT dose 27 mL/kg/h (range 19-54)] and one patient received CVV hemofiltration (CVVH). The mm mean levetiracetam CL during CVVHDF was 31.2 ± 8.5 mL/min, and the and the mean t_1/2 was 10.4 ± 2.2 h. For the patient requiring CVVH, clearance and t_1/2 were 22.5 mL/min and 9.5 h, respectively. Mean levetiracetam CL during SLED performed at a blood flow rate of 250 mL/min and a dialysate flow rate of 100 mL/min was 74.0 ± 25.3 mL/min and t_1/2 was 4.8 ± 2.3 h.

CONCLUSIONS

Levetiracetam clearance was substantial with both modalities under the operating conditions reported. There is the potential for subtherapeutic concentrations with current recommended dosing strategies that account only for kidney function and not these extracorporeal routes of elimination.

Effect of renal replacement therapy modalities on renal recovery and mortality for acute kidney injury: A PRISMA-compliant systematic review and meta-analysis

Previous investigations showed inconsistent results for comparison in renal recovery, in-hospital, and in-intensive care unit (ICU) mortalities between acute kidney injury (AKI) patients treated with continuous renal replacement therapy (CRRT) and some kinds of intermittent renal replacement therapies (IRRTs). We systematically searched for articles published in the databases (PubMed, Web of Science, EMBASE, Medline, and Google Scholar) until June 2019. We made all statistical analysis using STATA 12.0 software. In the present meta-analysis, relative risks with 95% confidence intervals were calculated for binary outcomes (renal recovery status or mortality). The present study indicated no significant differences in renal recovery, in-hospital mortality, and in-ICU mortality between AKI patients given CRRT and those given sustained low-efficiency dialysis (SLED). Additionally, the study showed no significant difference in in-hospital mortality between AKI patients given CRRT and those given intermittent hemodialysis (IHD), whereas elevated in-ICU mortality was detected in AKI patients given CRRT, compared to those given IHD. The three modalities (CRRT, IHD, and SLED) have their own advantages and disadvantages. More rigorous trials design with large cohort should be made to explore the differences in renal recovery, in-hospital, and in-ICU mortalities between different kinds of RRTs.

Renal Replacement Therapy in Acute Kidney Injury: Which Mode and When?

Renal replacement therapy (RRT) for acute kidney injury (AKI) patients in an intensive care unit (ICU) presents unique problems of providing biochemical and fluid removal in patients with unstable circulations, inotropes, and increased capillary permeability. Although no individual modality has been shown to confer a mortality benefit, it is assumed that continuous therapies like peritoneal dialysis (PD) and venovenous hemofiltration or hemodiafiltration may be better tolerated by the patient with hemodynamic instability, raised intracranial pressure (ICP), and liver failure. An individual patient may require more than one treatment in the course of his/her illness. The therapies offered may reflect available resources, local expertise, and cost constraints.

Renal Replacement Therapy in the Critical Care Setting

Renal replacement therapy (RRT) is frequently required to manage critically ill patients with acute kidney injury (AKI). There is limited evidence to support the current practice of RRT in intensive care units (ICUs). Recently published randomized control trials (RCTs) have further questioned our understanding of RRT in critical care. The optimal timing and dosing continues to be debatable; however, current evidence suggests delayed strategy with less intensive dosing when utilising RRT. Various modes of RRT are complementary to each other with no definite benefits to mortality or renal function preservation. Choice of anticoagulation remains regional citrate anticoagulation in continuous renal replacement therapy (CRRT) with lower bleeding risk when compared with heparin. RRT can be used to support resistant cardiac failure, but evolving therapies such as haemoperfusion are currently not recommended in sepsis.

Inadequate antibiotic dosing in patients receiving sustained low efficiency dialysis

Background Patients requiring SLED are often critically ill and/or hemodynamically unstable, and often need antibiotic therapy for life-threatening infections. Antibiotic dosing recommendations for intermittent hemodialysis and continuous renal replacement therapy are not appropriate for SLED and there is substantial concern for under dosing. Objective To characterize the adequacy of antibiotic dosing during SLED. Setting: Inpatient adult acute care hospital. Methods A retrospective chart review was performed for the period of October 2010 to August 2013 to identify patients who received SLED and at least one of the selected antibiotics: cefepime, daptomycin, piperacillin/tazobactam, meropenem, and vancomycin. Dosing regimens were evaluated each day the patient was receiving one of these antibiotics concurrently with SLED. The administered antibiotic dosing regimens were defined as "adequate" or "inadequate" based on recommendations available in the literature. Main outcome measure The percentage of adequate antibiotic days for each antibiotic. Results Antibiotic regimens were evaluated for a total of 51 patients: 35 (69%) with acute kidney injury, 16 (31%) with end-stage renal disease, mean SLED duration 9.3 ± 1.7 h. The total percent of adequate antibiotic days were: vancomycin 86%, cefepime 62%, daptomycin 58%, meropenem 35%, and piperacillin/tazobactam 20%. Under dosing accounted for 63% of the days antibiotic dosing was considered inadequate. Conclusion: Antibiotic dosing was frequently inadequate, especially for antibiotics requiring more frequent dosing, suggesting a high potential for subtherapeutic levels during the majority of time critically ill patients are requiring SLED.

Piperacillin Population Pharmacokinetics in Critically Ill Adults During Sustained Low-Efficiency Dialysis

BACKGROUND

Sustained low-efficiency dialysis (SLED), is increasingly being used in intensive care units (ICUs) but studies informing drug dosing for such patients is lacking.

OBJECTIVE

To describe the population pharmacokinetics (PKs) of piperacillin/tazobactam in critically ill adults receiving SLED and to provide dosing recommendations.

METHODS

This prospective population PK study was conducted in adult ICU patients prescribed piperacillin/tazobactam while receiving SLED; 321 blood samples were obtained from 34 participants during and between approximately 50 SLED treatments for quantification of piperacillin and tazobactam concentrations in plasma. A population PK model was developed. Monte Carlo simulation was used to determine the probability of target attainment and pathogen-specific fractional target attainment at different doses.

RESULTS

From a 2-compartment linear model with zero-order input, the mean (SD) clearance of piperacillin on SLED and off SLED were 4.81 (8.48) and 1.42 (1.54) L/h, respectively. Tazobactam concentrations were not sufficient for analysis. For the target of 50% fT>MIC (unbound concentrations of drug are above the minimum inhibitory concentration for >50% of the dosing interval), 3-g of piperacillin infused over 0.5 hours every 8 hours was appropriate for susceptible organisms with MIC ≤16 mg/L. For life-threatening infections where the target of 100% fT>MIC is preferred, a 9-g dose administered as a continuous infusion every 24 hours was appropriate for susceptible organisms with MIC ≤32 mg/L.

CONCLUSIONS AND RELEVANCE

In critically ill patients receiving SLED, piperacillin doses need to be guided by the frequency of SLED treatments and susceptibility of the known or suspected pathogen.

Interventions to prevent hemodynamic instability during renal replacement therapy in critically ill patients: a systematic review

Background

Hemodynamic instability related to renal replacement therapy (HIRRT) may increase the risk of death and limit renal recovery. Studies in end-stage renal disease populations on maintenance hemodialysis suggest that some renal replacement therapy (RRT)-related interventions (e.g., cool dialysate) may reduce the occurrence of HIRRT, but less is known about interventions to prevent HIRRT in critically ill patients receiving RRT for acute kidney injury (AKI). We sought to evaluate the effectiveness of RRT-related interventions for reducing HIRRT in such patients across RRT modalities.

Methods

A systematic review of publications was undertaken using MEDLINE, MEDLINE in Process, EMBASE, and Cochrane’s Central Registry for Randomized Controlled Trials (RCTs). Studies that assessed any intervention’s effect on HIRRT (the primary outcome) in critically ill patients with AKI were included. HIRRT was variably defined according to each study’s definition. Two reviewers independently screened abstracts, identified articles for inclusion, extracted data, and evaluated study quality using validated assessment tools.

Results

Five RCTs and four observational studies were included (n = 9; 623 patients in total). Studies were small, and the quality was mostly low. Interventions included dialysate sodium modeling (n = 3), ultrafiltration profiling (n = 2), blood volume (n = 2) and temperature control (n = 3), duration of RRT (n = 1), and slow blood flow rate at initiation (n = 1). Some studies applied more than one strategy simultaneously (n = 5). Interventions shown to reduce HIRRT from three studies (two RCTs and one observational study) included higher dialysate sodium concentration, lower dialysate temperature, variable ultrafiltration rates, or a combination of strategies. Interventions not found to have an effect included blood volume and temperature control, extended duration of intermittent RRT, and slower blood flow rates during continuous RRT initiation. How HIRRT was defined and its frequency of occurrence varied widely across studies, including those involving the same RRT modality. Pooled analysis was not possible due to study heterogeneity.

Conclusions

Small clinical studies suggest that higher dialysate sodium, lower temperature, individualized ultrafiltration rates, or a combination of these strategies may reduce the risk of HIRRT. Overall, for all RRT modalities, there is a paucity of high-quality data regarding interventions to reduce the occurrence of HIRRT in critically ill patients.

Electronic supplementary material

The online version of this article (10.1186/s13054-018-1965-5) contains supplementary material, which is available to authorized users.

Acute Kidney Injury in the Critically Ill

Acute kidney injury (AKI) occurs frequently in the surgical intensive care unit and results in significant morbidity and mortality. AKI needs to be identified early and underlying causes treated or eliminated. Sepsis, major surgery such as coronary artery bypass, and hypovolemia are the most common causes and patients with underlying comorbidities have increased susceptibility. Treatment should begin by ensuring that patients are adequately resuscitated and all contributing causes are replaced or eliminated. After stabilization of hemodynamic status and elimination of contributing causes, treatment becomes largely supportive and may require the use of a renal replacement therapy.

Issues of Acute Kidney Injury Staging and Management in Sepsis and Critical Illness: A Narrative Review

Acute kidney injury (AKI) has a high incidence on intensive care units around the world and is a major complication in critically ill patients suffering from sepsis or septic shock. The short- and long-term complications are thereby devastating and impair the quality of life. Especially in terms of AKI staging, the determination of kidney function and the timing of dialytic AKI management outside of life-threatening indications are ongoing matters of debate. Despite several studies, a major problem remains in distinguishing between beneficial and unnecessary "early" or even harmful renal replacement therapy (RRT). The latter might prolong disease course and renal recovery. AKI scores, however, provide an insufficient outcome-predicting ability and the related estimation of kidney function via serum creatinine or blood urea nitrogen (BUN)/urea is not reliable in AKI and critical illness. Kidney independent alterations of creatinine- and BUN/urea-levels further complicate the situation. This review critically assesses the current AKI staging, issues and pitfalls of the determination of kidney function and RRT timing, as well as the potential harm reflected by unnecessary RRT. A better understanding is mandatory to improve future study designs and avoid unnecessary RRT for higher patient safety and lower health care costs.