Comparing Continuous Venovenous Hemodiafiltration and Peritoneal Dialysis in Critically Ill Patients with Acute Kidney Injury: A Pilot Study (original) (raw)
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JAMA network open, 2019
IMPORTANCE Net ultrafiltration (NUF) is frequently used to treat fluid overload among critically ill patients, but whether the rate of NUF affects outcomes is unclear. OBJECTIVE To examine the association of NUF with survival among critically ill patients with acute kidney injury being treated with continuous venovenous hemodiafiltration. DESIGN, SETTING, AND PARTICIPANTS The Randomized Evaluation of Normal vs Augmented Level (RENAL) of Renal Replacement Therapy trial was conducted between December 30, 2005, and November 28, 2008, at 35 intensive care units in Australia and New Zealand among critically ill adults with acute kidney injury who were being treated with continuous venovenous hemodiafiltration. This secondary analysis began in May 2018 and concluded in January 2019. EXPOSURES Net ultrafiltration rate, defined as the volume of fluid removed per hour adjusted for patient body weight. MAIN OUTCOMES AND MEASURES Risk-adjusted 90-day survival. RESULTS Of 1434 patients, the median (interquartile range) age was 67.3 (56.9-76.3) years; 924 participants (64.4%) were male; median (interquartile range) Acute Physiology and Chronic Health Evaluation III score was 100 (84-118); and 634 patients (44.2%) died. Using tertiles, 3 groups were defined: high, NUF rate greater than 1.75 mL/kg/h; middle, NUF rate from 1.01 to 1.75 mL/kg/h; and low, NUF rate less than 1.01 mL/kg/h. The high-tertile group compared with the low-tertile group was not associated with death from day 0 to 6. However, death occurred in 51 patients (14.7%) in the high-tertile group vs 30 patients (8.6%) in the low-tertile group from day 7 to 12 (adjusted hazard ratio [aHR], 1.51; 95% CI, 1.13-2.02); 45 patients (15.3%) in the high-tertile group vs 25 patients (7.9%) in the low-tertile group from day 13 to 26 (aHR, 1.52; 95% CI, 1.11-2.07); and 48 patients (19.2%) in the high-tertile group vs 29 patients (9.9%) in the low-tertile group from day 27 to 90 (aHR, 1.66; 95% CI, 1.16-2.39). Every 0.5-mL/kg/h increase in NUF rate was associated with increased mortality
Medicine, 2018
Metabolic acid-base disorders, especially metabolic acidosis, are common in critically ill patients who require renal replacement therapy. Continuous veno-venous hemodiafiltration (CVVHDF) achieves profound changes in acid-base status, but metabolic acidosis can remain unchanged or even deteriorate in some patients. The objective of this study is to understand the changes of acid-base variables in critically ill patients with septic associated acute kidney injury (SA-AKI) during CVVHDF and to determine how they relate to clinical outcome.Observational study of 200 subjects with SA-AKI treated with CVVHDF for at least 72 hours. Arterial blood gases and electrolytes and other relevant acid-base variables were analyzed using quantitative acid-base chemistry.Survivors and nonsurvivors had similar demographic characteristics and acid-base variables on day one of CVVHDF. However, during the next 48 hours, the resolution of acidosis was significantly different between the 2 groups, with an...
PloS one, 2017
Several factors influence the outcomes in acute kidney injury (AKI), especially in intensive care unit (ICU) patients. In this scenario, continuous renal replacement therapies (CRRT) are used to control metabolic derangements and blood volume. Knowing this fact, it may be possible to change the course of the disease and decrease the high mortality rate observed. Thus, we aimed to evaluate the main risk factors for death in AKI patients needing CRRT. This was a prospective, observational cohort study of ICU patients (N = 183) with AKI who underwent continuous venovenous hemodiafiltration (CVVHDF) as their initial dialysis modality choice. The patients were predominantly male (62.8%) and their median age was 65 (55-76) years. The most frequent comorbidities were cardiovascular disease (39.3%), hypertension (32.8%), diabetes (24%), and cirrhosis (20.7%). The main cause of AKI was sepsis (52.5%). At beginning of CVVHDF, 152 patients (83%) were using vasopressors. The median SAPS 3 and S...
American Journal of Kidney Diseases, 2004
Background: Extended dialysis is an increasingly used modality of renal replacement therapy that theoretically offers advantages of both intermittent and continuous therapies in the intensive care unit (ICU). Methods: We randomly treated 39 ventilated critically ill patients with oliguric acute renal failure with either continuous venovenous hemofiltration (CVVH; n ؍ 19; age, 50.1 ؎ 3.2 years; Acute Physiology and Chronic Health Assessment II [APACHE II] score, 32.3 ؎ 1.2; 79% sepsis) and a substitution fluid rate of at least 30 mL/kg/h for 24 hours or with extended dialysis for 12 hours (n ؍ 20; age, 50.8 ؎ 3.6 years; APACHE II score, 33.6 ؎ 1.0; 85% sepsis). The latter was performed using an easy-to-handle, single-pass, batch dialysis system. All hemodynamic parameters were monitored invasively by means of an indwelling arterial catheter. Results: Average mean arterial blood pressure, heart rate, cardiac output, systemic vascular resistance, and catecholamine dose were not significantly different in both therapies. Urea reduction rate was similar with extended dialysis compared with CVVH therapy (53% ؎ 2% versus 52% ؎ 3%; P ؍ not significant) despite an average rate of substitution fluid with the latter of 3.2 ؎ 0.1 L/h. This was corroborated by the finding of similar amounts of urea eliminated in the collected spent total hemofiltration and dialysis fluid. Correction of acidosis was accomplished faster with extended dialysis than CVVH, and the amount of heparin used was significantly lower with extended dialysis (P < 0.01). Conclusion: Extended dialysis combines excellent detoxification with cardiovascular tolerability, even in severely ill patients in the ICU. The technically simple dialysis system used offers flexibility of treatment time. Am J Kidney Dis 43:342-349.
Nephron Extra, 2011
Background/Aims: In view of ongoing controversy, we wished to study whether patient characteristics and/or continuous venovenous hemofiltration (CVVH) characteristics contribute to the outcome of non-septic critically ill patients with acute kidney injury (AKI). Methods: We retrospectively studied 102 consecutive patients in the intensive care unit (ICU) with non-septic AKI needing CVVH. Patient and CVVH characteristics were evaluated. Primary outcome was mortality up to day 28 after CVVH initiation. Results: Forty-four patients (43%) died during the 28-day period after the start of CVVH. In univariate analyses, non-survivors had more often a cardiovascular reason for ICU admission, greater disease acuity/severity and organ failure, lower initial creatinine levels, less use of heparin and more use of bicarbonate-based substitution fluid. The latter two can be attributed to high lactate levels and bleeding tendency in non-survivors necessitating withholding lactate-buffered fluid and heparin, respectively, according to our clinical protocol. In multivariate analyses, mortality was predicted by disease severity, use of bicarbonate-based fluids and lack of heparin, while initial creatinine and CVVH dose did not contribute. Conclusion: The outcome of non-septic AKI in need of CVVH is more likely to be determined by underlying or concurrent, acute and severe disease rather than by CVVH characteristics, including timing and dose.
Kidney Research and Clinical Practice, 2012
Background: Continuous veno-venous hemodiafiltration (CVVHDF) is a preferred treatment modality in hemodynamically unstable acute kidney injury (AKI) patients, because it has advantages over intermittent dialysis in terms of hemodynamic stability. However, this patient group still shows a significantly high mortality rate. To aid in the management of these high-risk patients, we evaluated the risk factors for mortality in CVVHDF-treated hypotensive AKI patients. Methods: We studied 67 patients with AKI and hypotension who were treated with CVVHDF from February 2008 to August 2010. We reviewed patient characteristics and laboratory parameters to evaluate the risk factors for 90-day mortality. Results: Of the 67 enrolled patients (male:female¼42:25; mean age¼69714 years), 18 (27%) survived until 90 days after the initiation of CVVHDF. There was no significant difference in survival rates according to the etiology of AKI [hypovolemic shock 2/10 (20%), cardiogenic shock 4/20 (20%), septic shock 12/37 (32%)]. Univariate analysis did show significant differences between survivors and non-survivors in the frequency of ventilator use (44% vs. 76%, respectively; P¼0.02), APACHE II score (2977 vs. 3477, respectively; P¼ 0.01), SOFA score (1174 vs. 1374, respectively; P¼0.03), blood pH (7.370.1 vs. 7.270.1, respectively; P¼0.03), and rate of urine output o500 mL for 12 hours (50% vs. 80%, respectively; P¼0.03). A multivariate Cox proportional hazards model showed that a urine outputo500 mL for 12 hours was the only significant risk factor for 90-day mortality following CVVHDF treatment (odds ratio¼2.1, confidence interval¼1.01-4.4, P¼ 0.048). Conclusion: A urine outputo500 mL for 12 hours before the initiation of CVVHDF is an independent risk factor for 90-day mortality in hypotensive AKI patients treated with CVVHDF.
International Urology and Nephrology, 2012
Background Acute kidney injury (AKI) requiring dialysis in critically ill patients is associated with an inhospital mortality rate of 50-80 %. Extended daily hemodialysis (EHD) and high volume peritoneal dialysis (HVPD) have emerged as alternative modalities. Methods A double-center, randomized, controlled trial was conducted comparing EHD versus HVPD for the treatment for AKI in the intensive care unit (ICU). Four hundred and seven patients were randomized and 143 patients were analyzed. Principal outcome measure was hospital mortality, and secondary end points were recovery of renal function and metabolic and fluid control. Results There was no difference between the two groups in relation to median ICU stay [11 (5.7-20) vs. 9 (5.7-19)], recovery of kidney function (26.9 vs. 29.6 %, p = 0.11), need for chronic dialysis (9.7 vs. 6.5 %, p = 0.23), and hospital mortality (63.4 vs. 63.9 %, p = 0.94). The groups were different in metabolic and fluid control. Blood urea nitrogen (BUN), creatinine, and bicarbonate levels were stabilized faster in EHD group than in HVPD group. Delivered Kt/V and ultrafiltration were higher in EHD group. Despite randomization, there were significant differences between the groups in some covariates, including age, pre-dialysis BUN, and creatinine levels, biased in favor of the EHD. Using logistic regression to adjust for the imbalances in group assignment, the odds of death associated with HVPD was 1.4 (95 % CI 0.7-2.4, p = 0.19). A detailed investigation of the randomization process failed to explain the marked differences in patient assignment. Conclusions Despite faster metabolic control and higher dialysis dose and ultrafiltration with EHD, this study provides no evidence of a survival benefit of EHD compared with HVPD. The limitations of this study were that the results were not presented according to the intention to treat and it did not control other supportive management strategies as nutrition support and timing of dialysis initiation that might influence outcomes in AKI.
Blood Purification, 2013
Background: Urine alkalinisation with sodium bicarbonate decreases renal oxidative stress and might attenuate sepsis-associated acute kidney injury (s-AKI). Its safety and feasibility in patients at risk of s-AKI has never been tested. Methods: We randomly assigned patients at risk of s-AKI [systemic inflammatory response syndrome (SIRS), oliguria and elevated (≥150 μg/l) serum neutrophil gelatinase-associated lipocalin (NGAL) concentration] to receive a 0.5 mmol/kg bolus followed by a 0.2 mmol/kg/hr infusion of either sodium bicarbonate (treatment group) or sodium chloride (placebo group). Results: Among 50 patients with SIRS and oliguria, 25 (50%) had an elevated serum NGAL concentration. Of these, 13 were randomized to receive sodium bicarbonate and 12 to receive sodium chloride infusion. Study drugs were infused on average for a period of 25.9 ± 10.0 hours. Severe electrolyte abnormalities occurred in seven (28.0%) patients [four (30.8%) in treatment group vs. three (25%) in placebo group]. These abnormalities resulted in early protocol cessation in six (24.0%) patients and study drug suspension in one (4.0%). This adverse event rate was judged to be unacceptable and the study terminated early. There was no difference between the two groups in NGAL concentration over time, occurrence of AKI, requirement for renal replacement therapy, hospital length of stay and mortality. Conclusion: Administration of sodium bicarbonate and sodium chloride solutions in patients risk of s-AKI was associated with frequent major electrolyte abnormalities and early protocol cessation. The tested protocol does not appear safe or feasible. Clinical Trial Registration: NCT00706771.