1
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Rambaud T, Hajage D, Dreyfuss D, Lebbah S, 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, Bohe 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, Ashenoune K, Geri G, Klouche K, Thiery G, Argaud L, Rozec B, Cadoz C, Andreu P, Reignier J, Ricard JD, Quenot JP, Sonneville R, Gaudry S. Renal replacement therapy initiation strategies in comatose patients with severe acute kidney injury: a secondary analysis of a multicenter randomized controlled trial. Intensive Care Med 2024; 50:385-394. [PMID: 38407824 DOI: 10.1007/s00134-024-07339-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Accepted: 01/29/2024] [Indexed: 02/27/2024]
Abstract
PURPOSE The effect of renal replacement therapy (RRT) in comatose patients with acute kidney injury (AKI) remains unclear. We compared two RRT initiation strategies on the probability of awakening in comatose patients with severe AKI. METHODS We conducted a post hoc analysis of a trial comparing two delayed RRT initiation strategies in patients with severe AKI. Patients were monitored until they had oliguria for more than 72 h and/or blood urea nitrogen higher than 112 mg/dL and then randomized to a delayed strategy (RRT initiated after randomization) or a more-delayed one (RRT initiated if complication occurred or when blood urea nitrogen exceeded 140 mg/dL). We included only comatose patients (Richmond Agitation-Sedation scale [RASS] < - 3), irrespective of sedation, at randomization. A multi-state model was built, defining five mutually exclusive states: death, coma (RASS < - 3), incomplete awakening (RASS [- 3; - 2]), awakening (RASS [- 1; + 1] two consecutive days), and agitation (RASS > + 1). Primary outcome was the transition from coma to awakening during 28 days after randomization. RESULTS A total of 168 comatose patients (90 delayed and 78 more-delayed) underwent randomization. The transition intensity from coma to awakening was lower in the more-delayed group (hazard ratio [HR] = 0.36 [0.17-0.78]; p = 0.010). Time spent awake was 10.11 days [8.11-12.15] and 7.63 days [5.57-9.64] in the delayed and the more-delayed groups, respectively. Two sensitivity analyses were performed based on sedation status and sedation practices across centers, yielding comparable results. CONCLUSION In comatose patients with severe AKI, a more-delayed RRT initiation strategy resulted in a lower chance of transitioning from coma to awakening.
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Affiliation(s)
- Thomas Rambaud
- Département de Réanimation Médico-Chirurgicale, APHP Hôpital Avicenne, Bobigny, France
- Département de Médecine Intensive Réanimation Neuro, APHP Hôpital Pitié-Salpêtrière, Paris, France
| | - David Hajage
- Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP. Sorbonne Université, Hôpital Pitié Salpêtrière, 75013, Paris, France
| | - Didier Dreyfuss
- Common and Rare Kidney Diseases, Sorbonne Université, INSERM, UMR-S 1155, Paris, France
| | - Saïd Lebbah
- Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Sorbonne Université, Institut National de la Santé et de la Recherche Médicale (INSERM), Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP. Sorbonne Université, Hôpital Pitié Salpêtrière, 75013, Paris, France
| | | | - Guillaume Louis
- Réanimation Polyvalente, CHR Metz-Thionville Hôpital de Mercy, Metz, France
| | | | | | | | - Bertrand Pons
- Réanimation, CHU Pointe-à-Pitre/Abymes, Pointe-a-Pitre, France
| | | | - Sébastien Besset
- Médecine Intensive-Réanimation, APHP, Hôpital Louis Mourier, Colombes, France
| | - Alain Combes
- Service de Réanimation Médicale, AP-HP, Hôpital Pitié Salpêtrière, 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, Belfort, France
| | - Guillaume Chevrel
- Réanimation Polyvalente, CH Sud Francilien, Corbeil Essonnes, France
| | - Julien Bohe
- Anesthésie Réanimation Médicale et Chirurgicale, CH Lyon Sud Pierre Benite, Lyon, France
| | - Elisabeth Coupez
- Réanimation Polyvalente, Hôpital G. Montpied, Clermont Ferrand, France
| | - Nicolas Chudeau
- Réanimation Médico-Chirurgicale, CH du Mans, Le Mans, France
| | | | | | | | | | - Eric Boulet
- Réanimation et USC, GH Carnelle Portes de l'Oise, 95260, Beaumont Sur Oise, France
| | - Karim Lakhal
- Réanimation Chirurgicale Polyvalente, Hôpital Nord Laennec, Nantes, France
| | - Nadia Aissaoui
- Réanimation Médicale, Hôpital Georges Pompidou, Paris, France
| | | | - Marc Leone
- Anesthésie Réanimation, Hôpital Nord, Marseille, France
| | - Guillaume Lacave
- Réanimation Médico-Chirurgicale, Hôpital André Mignot, Versailles, France
| | - Saad Nseir
- Réanimation Médicale, CHRU de Lille, Hôpital Roger Salengro, Lille, France
| | - Florent Poirson
- Département de Réanimation Médico-Chirurgicale, APHP Hôpital Avicenne, Bobigny, France
| | - Julien Mayaux
- Pneumologie et Réanimation Médicale, Hôpital Pitié Salpêtrière, Paris, France
| | | | - Guillaume Geri
- Réanimation Médico-Chirurgicale, Hôpital Ambroise Paré, Boulogne-Billancourt, France
| | - Kada Klouche
- Médecine Intensive Réanimation,, Hôpital Lapeyronnie, Montpellier, France
| | - Guillaume Thiery
- Réanimation Médicale, CHU Saint Etienne, Saint Priest en Jarez, France
| | - Laurent Argaud
- Réanimation Médicale, Hôpital Edouard Herriot, Lyon, France
| | | | - Cyril Cadoz
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
| | - Pascal Andreu
- Médecine Intensive Réanimation, Hôtel Dieu, Nantes, France
| | | | - Jean-Damien Ricard
- Médecine Intensive-Réanimation, APHP, Hôpital Louis Mourier, Colombes, France
- Lipness Team, INSERM Research Center LNC-UMR1231 and LabExLipSTIC, University of Burgundy, Dijon, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France
- NSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France
| | - Romain Sonneville
- Médecine Intensive-Réanimation, AP-HP. Nord, Hôpital Bichat - Claude Bernard, Paris, France
- Université Paris Cité, INSERM UMR1137, IAME, 75018, Paris, France
| | - Stéphane Gaudry
- Département de Réanimation Médico-Chirurgicale, APHP Hôpital Avicenne, Bobigny, France.
- Common and Rare Kidney Diseases, Sorbonne Université, INSERM, UMR-S 1155, Paris, France.
- Health Care Simulation Center, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France.
- Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Bobigny, France.
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2
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Gaudry S, Grolleau F, Barbar S, Martin-Lefevre L, Pons B, Boulet É, Boyer A, Chevrel G, Montini F, Bohe J, Badie J, Rigaud JP, Vinsonneau C, Porcher R, Quenot JP, Dreyfuss D. Continuous renal replacement therapy versus intermittent hemodialysis as first modality for renal replacement therapy in severe acute kidney injury: a secondary analysis of AKIKI and IDEAL-ICU studies. Crit Care 2022; 26:93. [PMID: 35379300 PMCID: PMC8981658 DOI: 10.1186/s13054-022-03955-9] [Citation(s) in RCA: 20] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 03/03/2022] [Indexed: 01/05/2023] Open
Abstract
Background Intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) are the two main RRT modalities in patients with severe acute kidney injury (AKI). Meta-analyses conducted more than 10 years ago did not show survival difference between these two modalities. As the quality of RRT delivery has improved since then, we aimed to reassess whether the choice of IHD or CRRT as first modality affects survival of patients with severe AKI. Methods This is a secondary analysis of two multicenter randomized controlled trials (AKIKI and IDEAL-ICU) that compared an early RRT initiation strategy with a delayed one. We included patients allocated to the early strategy in order to emulate a trial where patients would have been randomized to receive either IHD or CRRT within twelve hours after the documentation of severe AKI. We determined each patient’s modality group as the first RRT modality they received. The primary outcome was 60-day overall survival. We used two propensity score methods to balance the differences in baseline characteristics between groups and the primary analysis relied on inverse probability of treatment weighting. Results A total of 543 patients were included. Continuous RRT was the first modality in 269 patients and IHD in 274. Patients receiving CRRT had higher cardiovascular and total-SOFA scores. Inverse probability weighting allowed to adequately balance groups on all predefined confounders. The weighted Kaplan–Meier death rate at day 60 was 54·4% in the CRRT group and 46·5% in the IHD group (weighted HR 1·26, 95% CI 1·01–1·60). In a complementary analysis of less severely ill patients (SOFA score: 3–10), receiving IHD was associated with better day 60 survival compared to CRRT (weighted HR 1.82, 95% CI 1·01–3·28; p < 0.01). We found no evidence of a survival difference between the two RRT modalities in more severe patients. Conclusion Compared to IHD, CRRT as first modality seemed to convey no benefit in terms of survival or of kidney recovery and might even have been associated with less favorable outcome in patients with lesser severity of disease. A prospective randomized non-inferiority trial should be implemented to solve the persistent conundrum of the optimal RRT technique. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-022-03955-9.
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Affiliation(s)
- Stéphane Gaudry
- Département de Réanimation Médico-Chirurgicale, APHP Hôpital Avicenne, Bobigny, France. .,Health Care Simulation Center, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France. .,Common and Rare Kidney Diseases, INSERM, UMR-S 1155, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France. .,Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Bobigny, France.
| | - François Grolleau
- Centre of Research in Epidemiology and Statistics (CRESS), Université de Paris, French Institute of Health and Medical Research (INSERM), National Institute of Agricultural Research (INRA), Paris, France
| | | | | | | | - Éric Boulet
- Réanimation Et USC, GH Carnelle Portes de L'Oise, 95260, Beaumont sur Oise, France
| | - Alexandre Boyer
- CHU de Bordeaux, Service de Réanimation Médicale, 33000, Bordeaux, France
| | | | - Florent Montini
- Réanimation Polyvalente, Centre Hospitalier d'Avignon, Avignon, France
| | - Julien Bohe
- Anesthésie Réanimation Médicale et Chirurgicale, CH Lyon Sud, Pierre Benite, France
| | - Julio Badie
- Réanimation Polyvalente, Hôpital Nord Franche-Comte CH Belfort, Belfort, France
| | | | - Christophe Vinsonneau
- Médecine Intensive Réanimation, CH Bethune Beuvry - Germont et Gauthier, Bethune, France
| | - Raphaël Porcher
- Centre of Research in Epidemiology and Statistics (CRESS), Université de Paris, French Institute of Health and Medical Research (INSERM), National Institute of Agricultural Research (INRA), 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
- Common and Rare Kidney Diseases, INSERM, UMR-S 1155, Hôpital Tenon, Sorbonne Université, 4 rue de la Chine, 75020, Paris, France.,Médecine Intensive-Réanimation, APHP, Hôpital Louis Mourier, Université de Paris, Colombes, France
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Timing of renal-replacement therapy in intensive care unit-related acute kidney injury. Curr Opin Crit Care 2021; 27:573-581. [PMID: 34757994 DOI: 10.1097/mcc.0000000000000891] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
PURPOSE OF REVIEW The optimal timing of renal-replacement therapy (RRT) initiation for the management of acute kidney injury (AKI) in the intensive care unit (ICU) is frequently controversial. An earlier-strategy has biological rationale, even in the absence of urgent indications; however, a delayed-strategy may prevent selected patients from receiving RRT and avoid complications related to RRT. RECENT FINDINGS Previous studies assessing the optimal timing of RRT initiation found conflicting results, contributing to variation in clinical practice. The recent multinational trial, standard vs. accelerated initiation of renal replacement therapy in acute kidney injury (STARRT-AKI) found no survival benefit and a higher risk of RRT dependence with an accelerated compared to a standard RRT initiation strategy in critically ill patients with severe AKI. Nearly 40% of patients allocated to the standard-strategy group did not receive RRT. The Artificial Kidney Initiation in Kidney Injury-2 (AKIKI-2) trial further assessed delayed compared to more-delayed strategies for RRT initiation. The more-delayed strategy did not confer an increase in RRT-free days and was associated with a higher risk of death. SUMMARY Early preemptive initiation of RRT in critically ill patients with AKI does not confer clear clinical benefits. However, protracted delays in RRT initiation may be harmful.
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4
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Quenot JP, Amrouche I, Lefrant JY, Klouche K, Jaber S, Du Cheyron D, Duranteau J, Maizel J, Rondeau E, Javouhey E, Gaillot T, Robert R, Dellamonica J, Souweine B, Bohé J, Barbar SD, Sejourné C, Vinsonneau C. Renal Replacement Therapy for Acute Kidney Injury in French Intensive Care Units: A Nationwide Survey of Practices. Blood Purif 2021; 51:698-707. [PMID: 34736254 DOI: 10.1159/000518919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2021] [Accepted: 08/04/2021] [Indexed: 11/19/2022]
Abstract
BACKGROUND The frequency of acute kidney injury (AKI) can be as high as 50% in the intensive care unit (ICU). Despite the publication of national guidelines in France in 2015 for the use of RRT, there are no data describing the implementation of these recommendations in real-life. METHODS We performed a nationwide survey of practices from November 15, 2019, to January 24, 2020, in France. An electronic questionnaire based on the items recommended in the national guidelines was sent using an online survey platform, to the chiefs of all ICUs in France. The questionnaire comprised a section for the Department Chief about local organization and facilities, and a second section destined for individual physicians about their personal practices. RESULTS We contacted the Department Chief in 356 eligible ICUs, of whom 88 (24.7%) responded regarding their ICU organization. From these 88 ICUs, 232/285 physicians (82%) completed the questionnaire regarding individual practices. The practices reported by respondent physicians were as follows: intermittent RRT was first-line choice in >75% in a patient with single organ (kidney) failure at the acute phase, whereas continuous RRT was predominant (>75%) in patients with septic shock or multi-organ failure. Blood and dialysate flow for intermittent RRT were 200-300 mL/min and 400-600 mL/min, respectively. The dose of dialysis for continuous RRT was 25-35 mL/kg/h (65%). Insertion of the dialysis catheter was mainly performed by the resident under echographic guidance, in the right internal jugular vein. The most commonly used catheter lock was citrate (53%). The most frequently cited criterion for weaning from RRT was diuresis, followed by a drop in urinary markers (urea and creatinine). CONCLUSION This study shows a satisfactory level of reported compliance with French guidelines and recent scientific evidence among ICU physicians regarding initiation of RRT for AKI in the ICU.
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Affiliation(s)
- Jean-Pierre Quenot
- Service de Médecine Intensive-Réanimation, CHU Dijon Bourgogne, Dijon, France.,Equipe Lipness, Centre de Recherche INSERM UMR1231, LabEx LipSTIC, Université de Bourgogne-Franche Comté, Dijon, France.,INSERM CIC 1432, Module Epidémiologie Clinique, Université de Bourgogne-Franche Comté, Dijon, France
| | - Idris Amrouche
- Service de Médecine Intensive-Réanimation, CHU Dijon Bourgogne, Dijon, France
| | - Jean-Yves Lefrant
- EA 2992 IMAGINE, Université de Montpellier, Montpellier, France.,Pôle Anesthésie Réanimation Douleur Urgence, CHU, Nîmes, France
| | - Kada Klouche
- Intensive Care Unit, Anaesthesiology and Intensive Care Department, Lapeyronie Hospital University Hospital and INM University Montpellier, INSERM, Montpellier, France
| | - Samir Jaber
- Department of Anesthesia and Critical Care Medicine, University of Montpellier Saint Eloi Hospital, and PhyMedExp, University of Montpellier, INSERM, CNRS, Montpellier, France
| | - Damien Du Cheyron
- BoReal Study Group, Medical Intensive Care Unit, Caen University Hospital, Caen, France
| | - Jacques Duranteau
- Anesthesia and Intensive Care Department, Hôpitaux Universitaires Paris Sud, Université Paris-Sud, Université Paris-Saclay, Hôpital de Bicêtre, Assistance Publique Hôpitaux de Paris (APHP), Le Kremlin-Bicêtre, France
| | - Julien Maizel
- BoReal Study Group, Medical Intensive Care Unit and EA7517, Amiens University Hospital, Amiens, France
| | - Eric Rondeau
- Department of Nephrology and Transplantation, AP-HP, Hôpital Tenon, Paris, France.,INSERM UMR-S 1155, Hospital Tenon, Paris, France.,Urgences Néphrologiques et Transplantation Rénale, Sorbonne Université, Paris, France
| | - Etienne Javouhey
- Paediatric Intensive Care Unit, Hospices Civils de Lyon, University of Lyon, Lyon, France.,Hospices Civils of Lyon, University Claude Bernard Lyon 1, Lyon, France
| | - Théophile Gaillot
- Service de Pédiatrie, Hôpital Sud, CHU de Rennes, Rennes, France.,CIC-P Inserm 0203 Université Rennes, Rennes, France
| | - René Robert
- Réanimation Médicale, CHU La Milétrie, Poitiers, France
| | - Jean Dellamonica
- Medical Intensive Care Unit, l'Archet Hospital, University Hospital of Nice, Nice, France
| | - Bertrand Souweine
- Service de Réanimation Médicale, CHU de Clermont-Ferrand, Clermont Ferrand, France
| | - Julien Bohé
- Service d'Anesthésie-Réanimation-Médecine Intensive, Centre Hospitalier Lyon-Sud, Hospices Civils de Lyon, Pierre Bénite, France
| | - Saber Davide Barbar
- Department of Anaesthesiology, Critical Care and Emergency Medicine, CHU Nïmes, University Montpellier, Nîmes, France
| | - Caroline Sejourné
- BoReal Study Group, Intensive Care Unit, Hôpital de Bethune, Bethune, France
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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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Gaudry S, Hajage D, Martin-Lefevre L, Lebbah S, Louis G, Moschietto S, Titeca-Beauport D, Combe BL, Pons B, de Prost N, Besset S, Combes A, Robine A, Beuzelin M, Badie J, Chevrel G, 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, Rozec B, Cadoz C, Andreu P, Reignier J, Ricard JD, Quenot JP, Dreyfuss D. Comparison of two delayed strategies for renal replacement therapy initiation for severe acute kidney injury (AKIKI 2): a multicentre, open-label, randomised, controlled trial. Lancet 2021; 397:1293-1300. [PMID: 33812488 DOI: 10.1016/s0140-6736(21)00350-0] [Citation(s) in RCA: 95] [Impact Index Per Article: 31.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/16/2020] [Revised: 12/21/2020] [Accepted: 02/03/2021] [Indexed: 01/09/2023]
Abstract
BACKGROUND Delaying renal replacement therapy (RRT) for some time in critically ill patients with severe acute kidney injury and no severe complication is safe and allows optimisation of the use of medical devices. Major uncertainty remains concerning the duration for which RRT can be postponed without risk. Our aim was to test the hypothesis that a more-delayed initiation strategy would result in more RRT-free days, compared with a delayed strategy. METHODS This was an unmasked, multicentre, prospective, open-label, randomised, controlled trial done in 39 intensive care units in France. We monitored critically ill patients with severe acute kidney injury (defined as Kidney Disease: Improving Global Outcomes stage 3) until they had oliguria for more than 72 h or a blood urea nitrogen concentration higher than 112 mg/dL. Patients were then randomly assigned (1:1) to either a strategy (delayed strategy) in which RRT was started just after randomisation or to a more-delayed strategy. With the more-delayed strategy, RRT initiation was postponed until mandatory indication (noticeable hyperkalaemia or metabolic acidosis or pulmonary oedema) or until blood urea nitrogen concentration reached 140 mg/dL. The primary outcome was the number of days alive and free of RRT between randomisation and day 28 and was done in the intention-to-treat population. The study is registered with ClinicalTrial.gov, NCT03396757 and is completed. FINDINGS Between May 7, 2018, and Oct 11, 2019, of 5336 patients assessed, 278 patients underwent randomisation; 137 were assigned to the delayed strategy and 141 to the more-delayed strategy. The number of complications potentially related to acute kidney injury or to RRT were similar between groups. The median number of RRT-free days was 12 days (IQR 0-25) in the delayed strategy and 10 days (IQR 0-24) in the more-delayed strategy (p=0·93). In a multivariable analysis, the hazard ratio for death at 60 days was 1·65 (95% CI 1·09-2·50, p=0·018) with the more-delayed versus the delayed strategy. The number of complications potentially related to acute kidney injury or renal replacement therapy did not differ between groups. INTERPRETATION In severe acute kidney injury patients with oliguria for more than 72 h or blood urea nitrogen concentration higher than 112 mg/dL and no severe complication that would mandate immediate RRT, longer postponing of RRT initiation did not confer additional benefit and was associated with potential harm. FUNDING Programme Hospitalier de Recherche Clinique.
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Affiliation(s)
- Stéphane Gaudry
- Département de réanimation médico-chirurgicale, APHP Hôpital Avicenne, Bobigny, France; Health Care Simulation Center, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France; Common and Rare Kidney Diseases, Sorbonne Université, INSERM, UMR-S 1155, Paris, France; Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Bobigny, France
| | - David Hajage
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Sorbonne Université, Hôpital Pitié Salpêtrière, Paris, France
| | | | - Saïd Lebbah
- INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Sorbonne Université, Hôpital Pitié Salpêtrière, Paris, France
| | - Guillaume Louis
- Réanimation polyvalente, CHR Metz-Thionville Hôpital de Mercy, Metz, France
| | | | | | | | - Bertrand Pons
- Réanimation, CHU Pointe-à-Pitre-Abymes, Pointe-a-Pitre, France
| | | | - Sébastien Besset
- Université de Paris, APHP, Hôpital Louis Mourier, DMU ESPRIT, Médecine Intensive-Réanimation, Colombes, France
| | - Alain Combes
- Service de Réanimation Médicale, Sorbonne Université, Hôpital Pitié Salpêtrière, 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, Belfort, France
| | | | - Julien Bohé
- Anesthésie réanimation médicale et chirurgicale, CH Lyon Sud, Pierre Benite
| | - Elisabeth Coupez
- Réanimation polyvalente, Hôpital G. Montpied, Clermont Ferrand, France
| | - Nicolas Chudeau
- Réanimation médico-chirurgicale, CH du Mans, Le Mans, France
| | | | | | | | | | - Eric Boulet
- Réanimation et USC, GH Carnelle Portes de l'Oise, Beaumont sur Oise, France
| | - Karim Lakhal
- Réanimation chirurgicale polyvalente, Hôpital Nord laennec, Nantes, France
| | - Nadia Aissaoui
- Réanimation médicale, Hôpital Georges Pompidou, Paris, France
| | | | - Marc Leone
- Anesthésie Réanimation, Hôpital Nord, Marseille, France
| | - Guillaume Lacave
- Réanimation médico-chirurgicale, Hôpital André Mignot, Versailles, France
| | - Saad Nseir
- Réanimation médicale, CHRU de Lille, Hôpital Roger Salengro, Lille, France
| | - Florent Poirson
- Département de réanimation médico-chirurgicale, APHP Hôpital Avicenne, Bobigny, France
| | - Julien Mayaux
- Pneumologie et Réanimation médicale, Sorbonne Université, Hôpital Pitié Salpêtrière, Paris, France
| | | | - Guillaume Geri
- Réanimation médico-chirurgicale, Hôpital Ambroise Paré, Boulogne-Billancourt, France
| | - Kada Klouche
- Médecine Intensive Réanimation, Hôpital Lapeyronnie, Montpellier, France
| | - Guillaume Thiery
- Réanimation médicale, CHU Saint Etienne, Saint Priest en Jarez, France
| | - Laurent Argaud
- Réanimation médicale, Hôpital Edouard Herriot, Lyon, France
| | | | - Cyril Cadoz
- Réanimation polyvalente, CHR Metz-Thionville Hôpital de Mercy, Metz, France
| | - Pascal Andreu
- Médecine intensive réanimation, Hôtel Dieu, Nantes, France
| | - Jean Reignier
- Médecine intensive réanimation, Hôtel Dieu, Nantes, France
| | - Jean-Damien Ricard
- Université de Paris, APHP, Hôpital Louis Mourier, DMU ESPRIT, Médecine Intensive-Réanimation, Colombes, France; INSERM, IAME, U1137, 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
- Common and Rare Kidney Diseases, Sorbonne Université, INSERM, UMR-S 1155, Paris, France; Université de Paris, APHP, Hôpital Louis Mourier, DMU ESPRIT, Médecine Intensive-Réanimation, Colombes, France.
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Abstract
PURPOSE OF REVIEW Over the past 5 years, four major randomized controlled trials were published informing our practice on the optimal timing for kidney replacement therapy (KRT) initiation in critically ill patients with acute kidney injury (AKI). In this review, we summarize the main findings of these trails and discuss the knowledge gaps that still need to be addressed. RECENT FINDINGS Four recent trials compared early versus delayed initiation of KRT in critically ill patients with acute kidney injury. Though each trial had unique design features, the three largest trials showed that earlier initiation of KRT did not reduce all-cause mortality. SUMMARY A preemptive strategy for initiation of kidney replacement therapy does not confer better survival in critically ill patients with severe AKI. However, early initiation of KRT was associated with a greater risk of iatrogenic complications and one trial showed a higher risk of persistent dialysis dependence. In the absence of absolute indications for KRT, clinicians should defer KRT initiation in patients with AKI. Further research is needed to examine the safety of prolonged KRT deferral and identify markers of fluid overload that may serve to trigger KRT initiation.
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8
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Sohaney R, Yessayan LT, Heung M. Towards Consensus in Timing of Kidney Replacement Therapy for Acute Kidney Injury? Am J Kidney Dis 2020; 77:542-545. [PMID: 32920155 DOI: 10.1053/j.ajkd.2020.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2020] [Accepted: 08/19/2020] [Indexed: 12/22/2022]
Affiliation(s)
- Ryann Sohaney
- Division of Nephrology, University of Michigan, Ann Arbor, MI
| | | | - Michael Heung
- Division of Nephrology, University of Michigan, Ann Arbor, MI.
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9
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Gameiro J, Fonseca JA, Outerelo C, Lopes JA. Acute Kidney Injury: From Diagnosis to Prevention and Treatment Strategies. J Clin Med 2020; 9:E1704. [PMID: 32498340 PMCID: PMC7357116 DOI: 10.3390/jcm9061704] [Citation(s) in RCA: 48] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2020] [Revised: 05/24/2020] [Accepted: 05/25/2020] [Indexed: 12/12/2022] Open
Abstract
Acute kidney injury (AKI) is characterized by an acute decrease in renal function that can be multifactorial in its origin and is associated with complex pathophysiological mechanisms. In the short term, AKI is associated with an increased length of hospital stay, health care costs, and in-hospital mortality, and its impact extends into the long term, with AKI being associated with increased risks of cardiovascular events, progression to chronic kidney disease (CKD), and long-term mortality. Given the impact of the prognosis of AKI, it is important to recognize at-risk patients and improve preventive, diagnostic, and therapy strategies. The authors provide a comprehensive review on available diagnostic, preventive, and treatment strategies for AKI.
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Affiliation(s)
- Joana Gameiro
- Department of Medicine, Division of Nephrology and Renal Transplantation, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal
| | - José Agapito Fonseca
- Department of Medicine, Division of Nephrology and Renal Transplantation, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal
| | - Cristina Outerelo
- Department of Medicine, Division of Nephrology and Renal Transplantation, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal
| | - José António Lopes
- Department of Medicine, Division of Nephrology and Renal Transplantation, Centro Hospitalar Lisboa Norte, EPE, Av. Prof. Egas Moniz, 1649-035 Lisboa, Portugal
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10
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Gaudry S, Hajage D, Benichou N, Chaïbi K, Barbar S, Zarbock A, Lumlertgul N, Wald R, Bagshaw SM, Srisawat N, Combes A, Geri G, Jamale T, Dechartres A, Quenot JP, Dreyfuss D. Delayed versus early initiation of renal replacement therapy for severe acute kidney injury: a systematic review and individual patient data meta-analysis of randomised clinical trials. Lancet 2020; 395:1506-1515. [PMID: 32334654 DOI: 10.1016/s0140-6736(20)30531-6] [Citation(s) in RCA: 122] [Impact Index Per Article: 30.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2020] [Revised: 02/10/2020] [Accepted: 02/26/2020] [Indexed: 12/15/2022]
Abstract
BACKGROUND The timing of renal replacement therapy (RRT) for severe acute kidney injury is highly debated when no life-threatening complications are present. We assessed whether a strategy of delayed versus early RRT initiation affects 28-day survival in critically ill adults with severe acute kidney injury. METHODS In this systematic review and individual patient data meta-analysis, we searched MEDLINE (via PubMed), Embase, and the Cochrane Central Register of Controlled Trials for randomised trials published from April 1, 2008, to Dec 20, 2019, that compared delayed and early RRT initiation strategies in patients with severe acute kidney injury. Trials were eligible for inclusion if they included critically ill patients aged 18 years or older with acute kidney injury (defined as a Kidney Disease: Improving Global Outcomes [KDIGO] acute kidney injury stage 2 or 3, or, where KDIGO was unavailable, a renal Sequential Organ Failure Assessment score of 3 or higher). We contacted the principal investigator of each eligible trial to request individual patient data. From the included trials, any patients without acute kidney injury or who were not randomly allocated were not included in the individual patient data meta-analysis. The primary outcome was all-cause mortality at day 28 after randomisation. This study is registered with PROSPERO (CRD42019125025). FINDINGS Among the 1031 studies identified, one study that met the eligibility criteria was excluded because the recruitment period was not recent enough, and ten (including 2143 patients) were included in the analysis. Individual patient data were available for nine studies (2083 patients), from which 1879 patients had severe acute kidney injury and were randomly allocated: 946 (50%) to the delayed RRT group and 933 (50%) to the early RRT group. 390 (42%) of 929 patients allocated to the delayed RRT group and who had available data did not receive RRT. The proportion of patients who died by day 28 did not significantly differ between the delayed RRT group (366 [44%] of 837) and the early RRT group (355 [43%] of 827; risk ratio 1·01 [95% CI 0·91 to 1·13], p=0·80), corresponding to an overall risk difference of 0·01 (95% CI -0·04 to 0·06). There was no heterogeneity across studies (I2=0%; τ2=0), and most studies had a low risk of bias. INTERPRETATION The timing of RRT initiation does not affect survival in critically ill patients with severe acute kidney injury in the absence of urgent indications for RRT. Delaying RRT initiation, with close patient monitoring, might lead to a reduced use of RRT, thereby saving health resources. FUNDING None.
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Affiliation(s)
- Stéphane Gaudry
- Département de Réanimation Médico-Chirurgicale, AP-HP Hôpital Avicenne, Bobigny, France; Health Care Simulation Center, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France; Common and Rare Kidney Diseases, Sorbonne Université, INSERM, UMR-S 1155, Paris, France; Investigation Network Initiative-Cardiovascular and Renal Clinical Trialists, Bobigny, France
| | - David Hajage
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Paris, France
| | - Nicolas Benichou
- Common and Rare Kidney Diseases, Sorbonne Université, INSERM, UMR-S 1155, Paris, France
| | - Khalil Chaïbi
- Common and Rare Kidney Diseases, Sorbonne Université, INSERM, UMR-S 1155, Paris, France
| | - Saber Barbar
- Département de Réanimation Médicale, Hôpital Carémeau, Nîmes, France
| | - Alexander Zarbock
- Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany
| | - Nuttha Lumlertgul
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Ron Wald
- Division of Nephrology, St Michael's Hospital and the University of Toronto, Toronto, ON, Canada
| | - Sean M Bagshaw
- Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Critical Care Nephrology Research Unit, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand; Tropical Medicine Cluster, Chulalongkorn University, Bangkok, Thailand; Excellence Center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Excellence Center for Critical Care Medicine, King Chulalongkorn Memorial Hospital, Bangkok, Thailand; Academy of Science, Royal Society of Thailand, Bangkok, Thailand
| | - Alain Combes
- INSERM, UMR-S 1166 ICAN, Institute of Cardiometabolism and Nutrition, Service de Médecine Intensive-Réanimation, Institut de Cardiologie, AP-HP Hôpital Pitié Salpêtrière, Sorbonne Université, Paris, France
| | - Guillaume Geri
- Service de Médecine Intensive Réanimation, AP-HP Hôpital Ambroise Paré, Université Paris-Saclay, INSERM UMR 1018, Paris, France
| | - Tukaram Jamale
- Department of Nephrology, Seth GS Medical College, KEM Hospital, Mumbai, India
| | - Agnès Dechartres
- Sorbonne Université, INSERM, Institut Pierre Louis d'Epidémiologie et de Santé Publique, AP-HP, Département de Santé Publique, Centre de Pharmacoépidémiologie (Cephepi), Paris, France
| | - Jean-Pierre Quenot
- Department of Intensive Care, François Mitterrand University Hospital, Dijon, France; Department of Lipness Team, INSERM Research Center LNC-UMR 1231 and LabExLipSTIC, University of Burgundy, Dijon, France; Department of Clinical Epidemiology, INSERM CIC 1432, University of Burgundy, Dijon, France
| | - Didier Dreyfuss
- Common and Rare Kidney Diseases, Sorbonne Université, INSERM, UMR-S 1155, Paris, France; Médecine Intensive-Réanimation, Université de Paris, AP-HP Hôpital Louis Mourier, Colombes, France.
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11
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Thongprayoon C, Hansrivijit P, Kovvuru K, Kanduri SR, Torres-Ortiz A, Acharya P, Gonzalez-Suarez ML, Kaewput W, Bathini T, Cheungpasitporn W. Diagnostics, Risk Factors, Treatment and Outcomes of Acute Kidney Injury in a New Paradigm. J Clin Med 2020; 9:E1104. [PMID: 32294894 PMCID: PMC7230860 DOI: 10.3390/jcm9041104] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/09/2020] [Accepted: 04/10/2020] [Indexed: 12/13/2022] Open
Abstract
Acute kidney injury (AKI) is a common clinical condition among patients admitted in the hospitals. The condition is associated with both increased short-term and long-term mortality. With the development of a standardized definition for AKI and the acknowledgment of the impact of AKI on patient outcomes, there has been increased recognition of AKI. Two advances from past decades, the usage of computer decision support and the discovery of AKI biomarkers, have the ability to advance the diagnostic method to and further management of AKI. The increasingly widespread use of electronic health records across hospitals has substantially increased the amount of data available to investigators and has shown promise in advancing AKI research. In addition, progress in the finding and validation of different forms of biomarkers of AKI within diversified clinical environments and has provided information and insight on testing, etiology and further prognosis of AKI, leading to future of precision and personalized approach to AKI management. In this this article, we discussed the changing paradigms in AKI: from mechanisms to diagnostics, risk factors, and management of AKI.
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Affiliation(s)
- Charat Thongprayoon
- Division of Nephrology, Department of Medicine, Mayo Clinic, Rochester, MN 55905, USA;
| | - Panupong Hansrivijit
- Department of Internal Medicine, University of Pittsburgh Medical Center Pinnacle, Harrisburg, PA 17105, USA;
| | - Karthik Kovvuru
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (K.K.); (S.R.K.); (M.L.G.-S.)
| | - Swetha R. Kanduri
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (K.K.); (S.R.K.); (M.L.G.-S.)
| | - Aldo Torres-Ortiz
- Department of Medicine, Ochsner Medical Center, New Orleans, LA 70121, USA;
| | - Prakrati Acharya
- Division of Nephrology, Department of Medicine, Texas Tech University Health Sciences Center, El Paso, TX 79905, USA;
| | - Maria L. Gonzalez-Suarez
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (K.K.); (S.R.K.); (M.L.G.-S.)
| | - Wisit Kaewput
- Department of Military and Community Medicine, Phramongkutklao College of Medicine, Bangkok 10400, Thailand;
| | - Tarun Bathini
- Department of Internal Medicine, University of Arizona, Tucson, AZ 85724, USA;
| | - Wisit Cheungpasitporn
- Division of Nephrology, Department of Medicine, University of Mississippi Medical Center, Jackson, MS 39216, USA; (K.K.); (S.R.K.); (M.L.G.-S.)
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