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Ness B, Heady B. Acute Kidney Injury. PHYSICIAN ASSISTANT CLINICS 2022. [DOI: 10.1016/j.cpha.2021.11.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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2
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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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3
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Li X, Liu C, Mao Z, Li Q, Zhou F. Timing of renal replacement therapy initiation for acute kidney injury in critically ill patients: a systematic review of randomized clinical trials with meta-analysis and trial sequential analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:15. [PMID: 33407756 PMCID: PMC7789484 DOI: 10.1186/s13054-020-03451-y] [Citation(s) in RCA: 35] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/02/2020] [Accepted: 12/22/2020] [Indexed: 12/18/2022]
Abstract
Background Acute kidney injury (AKI) is a common serious complication in critically ill patients. AKI occurs in up to 50% patients in intensive care unit (ICU), with poor clinical prognosis. Renal replacement therapy (RRT) has been widely used in critically ill patients with AKI. However, in patients without urgent indications such as acute pulmonary edema, severe acidosis, and severe hyperkalemia, the optimal timing of RRT initiation is still under debate. We conducted this systematic review of randomized clinical trials (RCTs) with meta-analysis and trial sequential analysis (TSA) to compare the effects of early RRT initiation versus delayed RRT initiation. Methods We searched databases (PubMed, EMBASE and Cochrane Library) from inception through to July 20, 2020, to identify eligible RCTs. The primary outcome was 28-day mortality. Two authors extracted the data independently. When the I2 values < 25%, we used fixed-effect mode. Otherwise, the random effects model was used as appropriate. TSA was performed to control the risk of random errors and assess whether the results in our meta-analysis were conclusive. Results Eleven studies involving 5086 patients were identified. Two studies included patients with sepsis, one study included patients with shock after cardiac surgery, and eight others included mixed populations. The criteria for the initiation of RRT, the definition of AKI, and RRT modalities existed great variations among the studies. The median time of RRT initiation across studies ranged from 2 to 7.6 h in the early RRT group and 21 to 57 h in the delayed RRT group. The pooled results showed that early initiation of RRT could not decrease 28-day all-cause mortality compared with delayed RRT (RR 1.01; 95% CI 0.94–1.09; P = 0.77; I2 = 0%). TSA result showed that the required information size was 2949. The cumulative Z curve crossed the futility boundary and reached the required information size. In addition, early initiation of RRT could lead to unnecessary RRT exposure in some patients and was associated with a higher incidence of hypotension (RR 1.42; 95% CI 1.23–1.63; P < 0.00001; I2 = 8%) and RRT-associated infection events (RR 1.34; 95% CI 1.01–1.78; P = 0.04; I2 = 0%). Conclusions This meta-analysis suggested that early initiation of RRT was not associated with survival benefit in critically ill patients with AKI. In addition, early initiation of RRT could lead to unnecessary RRT exposure in some patients, resulting in a waste of health resources and a higher incidence of RRT-associated adverse events. Maybe, only critically ill patients with a clear and hard indication, such as severe acidosis, pulmonary edema, and hyperkalemia, could benefit from early initiation of RRT.
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Affiliation(s)
- Xiaoming Li
- Department of Critical Care Medicine, the First Medical Centre, Chinese People's Liberation Army General Hospital, 28 Fu-Xing Road, Beijing, 100853, People's Republic of China.,Medical School of Chinese PLA, Beijing, People's Republic of China
| | - Chao Liu
- Medical School of Chinese PLA, Beijing, People's Republic of China
| | - Zhi Mao
- Department of Critical Care Medicine, the First Medical Centre, Chinese People's Liberation Army General Hospital, 28 Fu-Xing Road, Beijing, 100853, People's Republic of China
| | - Qinglin Li
- Department of Critical Care Medicine, the First Medical Centre, Chinese People's Liberation Army General Hospital, 28 Fu-Xing Road, Beijing, 100853, People's Republic of China
| | - Feihu Zhou
- Department of Critical Care Medicine, the First Medical Centre, Chinese People's Liberation Army General Hospital, 28 Fu-Xing Road, Beijing, 100853, People's Republic of China.
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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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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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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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Xiao L, Jia L, Li R, Zhang Y, Ji H, Faramand A. Early versus late initiation of renal replacement therapy for acute kidney injury in critically ill patients: A systematic review and meta-analysis. PLoS One 2019; 14:e0223493. [PMID: 31647828 PMCID: PMC6812871 DOI: 10.1371/journal.pone.0223493] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 09/22/2019] [Indexed: 02/06/2023] Open
Abstract
Background Acute kidney injury is associated with high mortality, and is the most frequent complication encountered in patients residing in the intensive care unit. Although renal replacement therapy (RRT) is the standard of care for acute kidney injury, the optimal timing for initiation is still unknown. Methods We conducted a systemic review and meta-analysis of randomized controlled trials evaluating early versus late initiation of RRT in critically ill patients with acute kidney injury. We searched MEDLINE, Embase, and CENTRAL databases from inception to October 15, 2018. We screened studies and extracted data from published reported independently. The primary outcome was short-term mortality. Results A total of 2242 patients were included from 11 trials. No statistically significant effect was found for early versus late initiation of RRT on short-term mortality (risk ratio [RR] 0.99, 95% CI 0.84–1.17, p = 0.93) or long-term mortality (RR 0.98, 95% CI 0.85–1.13, p = 0.76). There were also no statistically significant effects on ICU length of stay, hospital length of stay, recovery of renal function, and renal replacement therapy dependence. Early initiation of RRT decreased the risk of metabolic acidosis (RR 0.65, 95% CI 0.43–0.99, p = 0.04), but increased the risk of hypotension (RR 1.24, 95% CI 1.08–1.43, p = 0.003). Conclusions In critically ill patients with acute kidney injury, early compared with late initiation of RRT is not associated with favorable mortality outcomes, although it appears to reduce the risk of metabolic acidosis.
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Affiliation(s)
- Li Xiao
- Chengdu Women's and Children's Central Hospital, School of Medicine, University of Electronic Science and Technology of China,Chengdu, Sichuan, China
| | - Lu Jia
- Shanxi Provincial People’s Hospital, Taiyuan, China
| | - Rongshan Li
- Shanxi Provincial People’s Hospital, Taiyuan, China
| | - Yu Zhang
- Affiliated Hospital of Chengdu University, Chengdu, Sichuan, China
| | - Hongming Ji
- Shanxi Provincial People’s Hospital, Taiyuan, China
- * E-mail:
| | - Andrew Faramand
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States of America
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Old Wine in New Bottles: Continuous Versus Intermittent Renal Replacement Therapy in the ICU. Crit Care Med 2019; 46:340-341. [PMID: 29337800 DOI: 10.1097/ccm.0000000000002854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Pasin L, Boraso S, Tiberio I. Early initiation of renal replacement therapy in critically ill patients: a meta-analysis of randomized clinical trials. BMC Anesthesiol 2019; 19:62. [PMID: 31039744 PMCID: PMC6492439 DOI: 10.1186/s12871-019-0733-7] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2019] [Accepted: 04/10/2019] [Indexed: 12/26/2022] Open
Abstract
Background Acute kidney injury (AKI) is strongly associated with high morbidity and mortality of critically ill patients. In the last years several different biological markers with higher sensitivity and specificity for the occurrence of renal impairment have been developed in order to promptly recognize and treat AKI. Nonetheless, their potential role in improving patients’ outcome remains unclear since the effectiveness of an “earlier” initiation of renal replacement therapy (RRT) is still debated. Since one large, high-quality randomized clinical trial has been recently pubblished, we decided to perform a meta-analysis of all the RCTs ever performed on “earlier” initiation of RRT versus standard RRT in critically ill patients with AKI to evaluate its effect on major outcomes. Methods Pertinent studies were independently searched in BioMedCentral, PubMed, Embase, and Cochrane Central Register of clinical trials. The following inclusion criteria were used: random allocation to treatment (“earlier” initiation of RRT versus later/standard initiation); critically ill patients. Results Ten trials randomizing 2214 patients, 1073 to earlier initiation of RRT and 1141 to later initiation were included. No difference in mortality (43.3% (465 of 1073) for those receiving early RRT and 40.8% (466 of 1141) for controls, p = 0.97) and survival without dependence on RRT (3.6% (34 of 931) for those receiving early RRT and 4.2% (40 of 939) for controls, p = 0.51) were observed in the overall population. On the contrary, early initiation of RRT was associated with a significant reduction in hospital length of stay. No differences in occurrence of adverse events were observed. Conclusions Our study suggests that early initiation of RRT in critically ill patients with AKI does not provide a clinically relevant advantage when compared with standard/late initiation. Electronic supplementary material The online version of this article (10.1186/s12871-019-0733-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Laura Pasin
- Department of Anesthesia and Intensive Care, Ospedale S. Antonio, Via Facciolati, 71, Padova, Italy.
| | - Sabrina Boraso
- Department of Anesthesia and Intensive Care, Ospedale S. Antonio, Via Facciolati, 71, Padova, Italy
| | - Ivo Tiberio
- Department of Anesthesia and Intensive Care, Ospedale S. Antonio, Via Facciolati, 71, Padova, Italy
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Shum HP, Chan KC, Tam CWY, Yan WW, Chan TM. Impact of renal replacement therapy on survival in patients with KDIGO stage 3 acute kidney injury: A propensity score matched analysis. Nephrology (Carlton) 2019; 23:1081-1089. [PMID: 28898482 DOI: 10.1111/nep.13164] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 09/05/2017] [Indexed: 11/30/2022]
Abstract
AIM To investigate the impact of renal replacement therapy (RRT) on 90-day mortality in critically ill patients suffering from KDIGO stage 3 acute kidney injury (AKI) with or without life-threatening complications using propensity score matching analysis. METHODS We conducted a retrospective analysis of critically ill adult patients with KDIGO Stage 3 AKI with or without RRT during ICU stay between 1/1/2011-31/12/2013. Cox regression analysis and propensity score matching methods were used to determine predictors for 90-day mortality. RESULTS Among 661 patients, 50.5% received RRT. The unadjusted 90-day mortality rate was 42.5% and 54.1% in patients who had or had not received RRT, respectively. After adjustment with propensity score based on the probability of receiving RRT, the cox regression analysis showed that RRT was associated with a lower 90-day mortality (p<0.001). Among 322 propensity-matched pairs, RRT was associated with lower ICU (23.6% vs. 39.8%, p=0.002), hospital (33.5% vs. 55.9%, p<0.001) and 90-day mortality (34.2% vs. 58.4%, p<0.001), and a higher 90-day renal recovery rate (57.8% vs. 45.3% full recovery, p=0.026) compared with no RRT. When an alternate propensity model was used, the benefits associated with RRT were very similar, except 90-day renal recovery became insignificant. CONCLUSION Our observational study found that in critically ill patients with KDIGO Stage 3 AKI, RRT may be associated with lower 90-day mortality. The benefit of RRT on renal recovery was less prominent. Medical futility and practice variations may complicate study interpretation. To avoid these limitations, large-scale multicenter, non-observational study is recommended.
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Affiliation(s)
- Hoi-Ping Shum
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - King-Chung Chan
- Department of Anesthesia and Intensive Care, TuenMun Hospital, Hong Kong, China
| | - Catherine W-Y Tam
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - Wing-Wa Yan
- Department of Intensive Care, Pamela Youde Nethersole Eastern Hospital, Hong Kong, China
| | - Tak-Mao Chan
- Department of Medicine, The University of Hong Kong, Queen Mary Hospital, Hong Kong, China
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11
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Srisawat N, Tangvoraphonkchai K, Lumlertgul N, Tungsanga K, Eiam-Ong S. Role of acute kidney injury biomarkers to guide renal replacement therapy initiation, what we learn from EARLY-RRT trial and FST trial? J Thorac Dis 2019; 10:E835-E838. [PMID: 30746270 DOI: 10.21037/jtd.2018.11.95] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | | | - Nuttha Lumlertgul
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Kriang Tungsanga
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, King Chulalongkorn Memorial Hospital, Bangkok, Thailand
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12
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Hoste EA, Vandenberghe W. Plasma neutrophil gelatinase-associated lipocalin (NGAL) for timing of initiation of renal replacement therapy for acute kidney injury? J Thorac Dis 2019; 10:S3989-S3993. [PMID: 30631536 DOI: 10.21037/jtd.2018.09.110] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Eric A Hoste
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium.,Research Foundation-Flanders (FWO), Brussels, Belgium
| | - Wim Vandenberghe
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent University, Ghent, Belgium
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13
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Stads S, Schilder L, Nurmohamed SA, Bosch FH, Purmer IM, den Boer SS, Kleppe CG, Vervloet MG, Beishuizen A, Girbes ARJ, ter Wee PM, Gommers D, Groeneveld ABJ, Oudemans-van Straaten HM. Fluid balance-adjusted creatinine at initiation of continuous venovenous hemofiltration and mortality. A post-hoc analysis of a multicenter randomized controlled trial. PLoS One 2018; 13:e0197301. [PMID: 29874271 PMCID: PMC5991340 DOI: 10.1371/journal.pone.0197301] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2017] [Accepted: 04/27/2018] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Acute kidney injury (AKI) requiring renal replacement therapy (RRT) is associated with high mortality. The creatinine-based stage of AKI is considered when deciding to start or delay RRT. However, creatinine is not only determined by renal function (excretion), but also by dilution (fluid balance) and creatinine generation (muscle mass). The aim of this study was to explore whether fluid balance-adjusted creatinine at initiation of RRT is related to 28-day mortality independent of other markers of AKI, surrogates of muscle mass and severity of disease. METHODS We performed a post-hoc analysis on data from the multicentre CASH trial comparing citrate to heparin anticoagulation during continuous venovenous hemofiltration (CVVH). To determine whether fluid balance-adjusted creatinine was associated with 28-day mortality, we performed a logistic regression analysis adjusting for confounders of creatinine generation (age, gender, body weight), other markers of AKI (creatinine, urine output) and severity of disease. RESULTS Of the 139 patients, 32 patients were excluded. Of the 107 included patients, 36 died at 28 days (34%). Non-survivors were older, had higher APACHE II and inclusion SOFA scores, lower pH and bicarbonate, lower creatinine and fluid balance-adjusted creatinine at CVVH initiation. In multivariate analysis lower fluid balance-adjusted creatinine (OR 0.996, 95% CI 0.993-0.999, p = 0.019), but not unadjusted creatinine, remained associated with 28-day mortality together with bicarbonate (OR 0.869, 95% CI 0.769-0.982, P = 0.024), while the APACHE II score non-significantly contributed to the model. CONCLUSION In this post-hoc analysis of a multicentre trial, low fluid balance-adjusted creatinine at CVVH initiation was associated with 28-day mortality, independent of other markers of AKI, organ failure, and surrogates of muscle mass, while unadjusted creatinine was not. More tools are needed for better understanding of the complex determinants of "AKI classification", "CVVH initiation" and their relation with mortality, fluid balance is only one.
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Affiliation(s)
- Susanne Stads
- Department of Intensive care, Erasmus Medical Center, Rotterdam, the Netherlands
- Department of Intensive care, Ikazia Hospital, Rotterdam, the Netherlands
| | - Louise Schilder
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
| | - S. Azam Nurmohamed
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
| | - Frank H. Bosch
- Department of Intensive Care, Rijnstate Hospital, Arnhem, the Netherlands
| | - Ilse M. Purmer
- Department of Intensive care, Haga hospital, den Haag, the Netherlands
| | - Sylvia S. den Boer
- Department of Intensive care, Spaarne Gasthuis, Hoofddorp, the Netherlands
| | - Cynthia G. Kleppe
- Department of Intensive care, Noordwest Ziekenhuis groep, Alkmaar, the Netherlands
| | - Marc G. Vervloet
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
| | - Albertus Beishuizen
- Department of Intensive care, VU University Medical Center, Amsterdam, the Netherlands
- Department of Intensive care, Medical Spectrum, Twente, the Netherlands
| | - Armand R. J. Girbes
- Department of Intensive care, VU University Medical Center, Amsterdam, the Netherlands
| | - Pieter M. ter Wee
- Department of Nephrology, VU University Medical Center, Amsterdam, the Netherlands
| | - Diederik Gommers
- Department of Intensive care, Erasmus Medical Center, Rotterdam, the Netherlands
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14
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Negi S, Koreeda D, Kobayashi S, Yano T, Tatsuta K, Mima T, Shigematsu T, Ohya M. Acute kidney injury: Epidemiology, outcomes, complications, and therapeutic strategies. Semin Dial 2018; 31:519-527. [PMID: 29738093 DOI: 10.1111/sdi.12705] [Citation(s) in RCA: 70] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Acute kidney injury (AKI) is one of the most common serious complications for all hospital admissions, with its incidence increasing among hospitalized patients, particularly those in the intensive care unit. Despite significant improvements in critical care and dialysis technology, AKI is associated with an increased risk of short- and long-term mortality, prolonged hospital stays, and dialysis dependence. These risks are particularly relevant for critically ill patients with AKI severe enough to require renal replacement therapy (RRT). No specific pharmacologic treatment has been established to treat AKI. Hence, the mainstay treatment for patients with AKI is RRT even though there are still several problematic issues regarding its use including RRT modality, dose, and timing. Recently, the impact of AKI on an increased risk of progression to chronic kidney disease (CKD) and end-stage renal disease requiring dialysis or transplantation is attracting increased attention.
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Affiliation(s)
- Shigeo Negi
- Department of Nephrology, Wakayama Medical University, Wakayama, Japan
| | - Daisuke Koreeda
- Department of Nephrology, Wakayama Medical University, Wakayama, Japan
| | - Sou Kobayashi
- Department of Nephrology, Wakayama Medical University, Wakayama, Japan
| | - Takuro Yano
- Department of Nephrology, Wakayama Medical University, Wakayama, Japan
| | - Koichi Tatsuta
- Department of Nephrology, Wakayama Medical University, Wakayama, Japan
| | - Toru Mima
- Department of Nephrology, Wakayama Medical University, Wakayama, Japan
| | | | - Masaki Ohya
- Department of Nephrology, Wakayama Medical University, Wakayama, Japan
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15
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Lumlertgul N, Peerapornratana S, Trakarnvanich T, Pongsittisak W, Surasit K, Chuasuwan A, Tankee P, Tiranathanagul K, Praditpornsilpa K, Tungsanga K, Eiam-Ong S, Kellum JA, Srisawat N. Early versus standard initiation of renal replacement therapy in furosemide stress test non-responsive acute kidney injury patients (the FST trial). CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:101. [PMID: 29673370 PMCID: PMC5909278 DOI: 10.1186/s13054-018-2021-1] [Citation(s) in RCA: 88] [Impact Index Per Article: 14.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2018] [Accepted: 03/27/2018] [Indexed: 03/24/2023]
Abstract
Background The timing of initiation of renal replacement therapy (RRT) in severe acute kidney injury (AKI) remains controversial, with early initiation resulting in unnecessary therapy for some patients while expectant therapy may delay RRT for other patients. The furosemide stress test (FST) has been shown to predict the need for RRT and therefore could be used to exclude low-risk patients from enrollment in trials of RRT timing. We conducted this multicenter pilot study to determine whether FST could be used to screen patients at high risk for RRT and to determine the feasibility of incorporating FST into a trial of early initiation of RRT. Methods FST was performed using intravenous furosemide (1 mg/kg in furosemide-naive patients or 1.5 mg/kg in previous furosemide users). FST-nonresponsive patients (urine output less than 200 mL in 2 h) were then randomized to early (initiation within 6 h) or standard (initiation by urgent indication) RRT. Results FST was completed in all patients (100%). Only 6/44 (13.6%) FST-responsive patients ultimately received RRT while 47/60 (78.3%) nonresponders randomized to standard RRT either received RRT or died (P < 0.001). Among 118 FST-nonresponsive patients, 98.3% in the early RRT arm and 75% in the standard RRT arm received RRT. The adherence to the protocol was 94.8% and 100% in the early and standard RRT group, respectively. We observed no differences in 28-day mortality (62.1 versus 58.3%, P = 0.68), 7-day fluid balance, or RRT dependence at day 28. However, hypophosphatemia occurred more frequently in the early RRT arm (P = 0.002). Conclusion The furosemide stress test appears to be feasible and effective in identifying patients for randomization to different RRT initiation times. Our findings should guide implementation of large-scale randomized controlled trials for the timing of RRT initiation. Trial registration clinicaltrials.gov, NCT02730117. Registered 6 April 2016. Electronic supplementary material The online version of this article (10.1186/s13054-018-2021-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Nuttha Lumlertgul
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Sadudee Peerapornratana
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand.,Excellence center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
| | - Thananda Trakarnvanich
- Renal Division, Department of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | - Wanjak Pongsittisak
- Renal Division, Department of Medicine, Vajira Hospital, Navamindradhiraj University, Bangkok, Thailand
| | | | | | | | - Khajohn Tiranathanagul
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kearkiat Praditpornsilpa
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Kriang Tungsanga
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - Somchai Eiam-Ong
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
| | - John A Kellum
- The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Nattachai Srisawat
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand. .,Excellence center for Critical Care Nephrology, King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand. .,The Center for Critical Care Nephrology, CRISMA, Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
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Ye Y, Yang M, Zhang S, Zeng Y. Percutaneous coronary intervention versus cardiac bypass surgery for left main coronary artery disease: A trial sequential analysis. Medicine (Baltimore) 2017; 96:e8115. [PMID: 29019879 PMCID: PMC5662302 DOI: 10.1097/md.0000000000008115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Several updated meta-analyses comparing percutaneous coronary intervention (PCI) with coronary artery bypass grafting (CABG) for left main coronary artery disease (LM CAD) have been published recently. However, the risk of false-positive results could be high in conventional updated meta-analyses due to repetitive testing of accumulating data. Therefore, we compared these treatment approaches via trial sequential analysis (TSA). METHODS The MEDLINE, Embase, and Cochrane Central Register of Controlled Trials databases were searched for published randomized controlled trials (RCTs) or subgroups of RCTs comparing PCI and CABG in patients with LM CAD. The primary outcome was major cardiac and cerebrovascular adverse events (MACCE). TSA was used to confirm the conclusions derived from conventional meta-analysis. RESULTS Six RCTs with 4700 patients were included. PCI was associated with a greater risk of MACCE compared with CABG (pooled relative risk [RR] 1.21, 95% confidence interval [CI]: 1.05-1.40, P = .008). In addition, PCI resulted in a significantly higher risk of revascularization than CABG (pooled RR 1.61, 95% CI: 1.33-1.95, P < .0001). TSA provided firm evidence for the reduction of MACCE and revascularization with CABG compared with PCI (cumulative z-curve crossed the monitoring boundary). In the subgroup analysis, CABG was better than PCI in patients with SYNTAX score >32 (pooled RR 1.41, 95% CI: 1.12-1.76, P = .003), which was confirmed by the TSA. There was no difference in patients with a SYNTAX score from 0 to 32. CONCLUSIONS In patients with LM CAD, CABG may be better than PCI for reducing MACCE due to a reduced risk of revascularization. CABG remains the first choice for LM CAD patients with high anatomic complexity, while PCI could be an alternative for those with low-to-moderate anatomic complexity.
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