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Continuous renal replacement therapy versus intermittent hemodialysis in intensive care patients: impact on mortality and renal recovery

Anne-Sophie Truche| Michael Darmon| Sébastien Bailly| Christophe Clec’h| Claire Dupuis| Benoit Misset| Elie Azoulay| Carole Schwebel| Lila Bouadma| Hatem Kallel| Christophe Adrie| Anne-Sylvie Dumenil| Laurent Argaud| Guillaume Marcotte| Samir Jamali| Philippe Zaoui| Virginie Laurent| Dany Goldgran-Toledano| Romain Sonneville| Bertrand Souweine| Jean-Francois Timsit
Original
Volume 42, Issue 9 / September , 2016

Pages 1408 - 1417

Abstract

Purpose

The best renal replacement therapy (RRT) modality remains controversial. We compared mortality and short- and long-term renal recovery between patients treated with continuous RRT and intermittent hemodialysis.

Methods

Patients of the prospective observational multicenter cohort database OUTCOMEREA™ were included if they underwent at least one RRT session between 2004 and 2014. Differences in patients’ baseline and daily characteristics between treatment groups were taken into account by using a marginal structural Cox model, allowing one to substantially reduce the bias resulting from confounding factors in observational longitudinal data analysis. The composite primary endpoint was 30-day mortality and dialysis dependency.

Results

Among 1360 included patients with RRT, 544 (40.0 %) and 816 (60.0 %) were initially treated by continuous RRT and intermittent hemodialysis, respectively. At day 30, 39.6 % patients were dead. Among survivors, 23.8 % still required RRT. There was no difference between groups for the primary endpoint in global population (HR 1.00, 95 % CI 0.77–1.29; p = 0.97). In patients with higher weight gain at RRT initiation, mortality and dialysis dependency were significantly lower with continuous RRT (HR 0.54, 95 % CI 0.29–0.99; p = 0.05). Conversely, this technique appeared to be deleterious in patients without shock (HR 2.24, 95 % CI 1.24–4.04; p = 0.01). Six-month mortality and persistent renal dysfunction were not influenced by the RRT modality in patients with dialysis dependence at ICU discharge.

Conclusion

Continuous RRT did not appear to improve 30-day and 6-month patient outcomes. It seems beneficial for patients with fluid overload, but might be deleterious in the absence of hemodynamic failure.

Keywords

References

  1. Clec’h C, Gonzalez F, Lautrette A, Nguile-Makao M, Garrouste-Orgeas M, Jamali S, Golgran-Toledano D, Descorps-Declere A, Chemouni F, Hamidfar-Roy R, Azoulay E, Timsit JF (2011) Multiple-center evaluation of mortality associated with acute kidney injury in critically ill patients: a competing risks analysis. Crit Care 15:R128
    • View reference on publisher's website
    • View reference on PubMed
  2. Clec’h C, Darmon M, Lautrette A, Chemouni F, Azoulay E, Schwebel C, Dumenil AS, Garrouste-Orgeas M, Goldgran-Toledano D, Cohen Y, Timsit JF (2012) Efficacy of renal replacement therapy in critically ill patients: a propensity analysis. Crit Care 16:R236
    • View reference on publisher's website
    • View reference on PubMed
  3. Gammelager H, Christiansen CF, Johansen MB, Tonnesen E, Jespersen B, Sorensen HT (2013) Five-year risk of end-stage renal disease among intensive care patients surviving dialysis-requiring acute kidney injury: a nationwide cohort study. Crit Care 17:R145
    • View reference on publisher's website
    • View reference on PubMed
  4. Bagshaw SM, Berthiaume LR, Delaney A, Bellomo R (2008) Continuous versus intermittent renal replacement therapy for critically ill patients with acute kidney injury: a meta-analysis. Crit Care Med 36:610–617
    • View reference on publisher's website
    • View reference on PubMed
  5. Rabindranath K, Adams J, Macleod AM, Muirhead N (2007) Intermittent versus continuous renal replacement therapy for acute renal failure in adults. Cochrane Database Syst Rev: CD003773
  6. Vinsonneau C, Camus C, Combes A, Costa de Beauregard MA, Klouche K, Boulain T, Pallot JL, Chiche JD, Taupin P, Landais P, Dhainaut JF (2006) Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. Lancet 368:379–385
    • View reference on publisher's website
    • View reference on PubMed
  7. Lins RL, Elseviers MM, Van der Niepen P, Hoste E, Malbrain ML, Damas P, Devriendt J (2009) Intermittent versus continuous renal replacement therapy for acute kidney injury patients admitted to the intensive care unit: results of a randomized clinical trial. Nephrol Dial Transplant 24:512–518
    • View reference on publisher's website
    • View reference on PubMed
  8. Misset B, Timsit JF, Chevret S, Renaud B, Tamion F, Carlet J (1996) A randomized cross-over comparison of the hemodynamic response to intermittent hemodialysis and continuous hemofiltration in ICU patients with acute renal failure. Intensive Care Med 22:742–746
  9. Mehta RL, McDonald B, Gabbai FB, Pahl M, Pascual MT, Farkas A, Kaplan RM (2001) A randomized clinical trial of continuous versus intermittent dialysis for acute renal failure. Kidney Int 60:1154–1163
    • View reference on publisher's website
    • View reference on PubMed
  10. Gasparovic V, Filipovic-Grcic I, Merkler M, Pisl Z (2003) Continuous renal replacement therapy (CRRT) or intermittent hemodialysis (IHD)–what is the procedure of choice in critically ill patients? Ren Fail 25:855–862
    • View reference on publisher's website
    • View reference on PubMed
  11. Schneider AG, Bellomo R, Bagshaw SM, Glassford NJ, Lo S, Jun M, Cass A, Gallagher M (2013) Choice of renal replacement therapy modality and dialysis dependence after acute kidney injury: a systematic review and meta-analysis. Intensive Care Med 39:987–997
  12. Wald R, Shariff SZ, Adhikari NK, Bagshaw SM, Burns KE, Friedrich JO, Garg AX, Harel Z, Kitchlu A, Ray JG (2014) The association between renal replacement therapy modality and long-term outcomes among critically ill adults with acute kidney injury: a retrospective cohort study. Crit Care Med 42:868–877
    • View reference on publisher's website
    • View reference on PubMed
  13. KDIGO (2011) Section 5: dialysis interventions for treatment of AKI. Kidney Int Suppl 2:89–115
  14. Benson K, Hartz AJ (2000) A comparison of observational studies and randomized, controlled trials. N Engl J Med 342:1878–1886
    • View reference on publisher's website
    • View reference on PubMed
  15. Robins JM, Hernan MA, Brumback B (2000) Marginal structural models and causal inference in epidemiology. Epidemiology 11:550–560
    • View reference on publisher's website
    • View reference on PubMed
  16. Clec’h C, Alberti C, Vincent F, Garrouste-Orgeas M, de Lassence A, Toledano D, Azoulay E, Adrie C, Jamali S, Zaccaria I, Cohen Y, Timsit JF (2007) Tracheostomy does not improve the outcome of patients requiring prolonged mechanical ventilation: a propensity analysis. Crit Care Med 35:132–138
    • View reference on publisher's website
    • View reference on PubMed
  17. Uehlinger DE, Jakob SM, Ferrari P, Eichelberger M, Huynh-Do U, Marti HP, Mohaupt MG, Vogt B, Rothen HU, Regli B, Takala J, Frey FJ (2005) Comparison of continuous and intermittent renal replacement therapy for acute renal failure. Nephrol Dial Transplant 20:1630–1637
    • View reference on publisher's website
    • View reference on PubMed
  18. John S, Griesbach D, Baumgartel M, Weihprecht H, Schmieder RE, Geiger H (2001) Effects of continuous haemofiltration vs intermittent haemodialysis on systemic haemodynamics and splanchnic regional perfusion in septic shock patients: a prospective, randomized clinical trial. Nephrol Dial Transplant 16:320–327
    • View reference on publisher's website
    • View reference on PubMed
  19. Davenport A (2009) Continuous renal replacement therapies in patients with acute neurological injury. Semin Dial 22:165–168
    • View reference on publisher's website
    • View reference on PubMed
  20. Palevsky PM, Zhang JH, O’Connor TZ, Chertow GM, Crowley ST, Choudhury D, Finkel K, Kellum JA, Paganini E, Schein RM, Smith MW, Swanson KM, Thompson BT, Vijayan A, Watnick S, Star RA, Peduzzi P (2008) Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med 359:7–20
    • View reference on publisher's website
    • View reference on PubMed
  21. Bailly S, Pirracchio R, Timsit JF (2016) What’s new in the quantification of causal effects from longitudinal cohort studies: a brief introduction to marginal structural models for intensivists. Intensive Care Med 42:576–579
  22. Hernan MA, Brumback B, Robins JM (2000) Marginal structural models to estimate the causal effect of zidovudine on the survival of HIV-positive men. Epidemiology 11:561–570
    • View reference on publisher's website
    • View reference on PubMed
  23. Vaara ST, Reinikainen M, Wald R, Bagshaw SM, Pettila V (2014) Timing of RRT based on the presence of conventional indications. Clin J Am Soc Nephrol 9:1577–1585
    • View reference on publisher's website
    • View reference on PubMed
  24. Bellomo R, Ronco C (1999) Continuous renal replacement therapy in the intensive care unit. Intensive Care Med 25:781–789
  25. Augustine JJ, Sandy D, Seifert TH, Paganini EP (2004) A randomized controlled trial comparing intermittent with continuous dialysis in patients with ARF. Am J Kidney Dis 44:1000–1007
    • View reference on publisher's website
    • View reference on PubMed
  26. Schortgen F, Soubrier N, Delclaux C, Thuong M, Girou E, Brun-Buisson C, Lemaire F, Brochard L (2000) Hemodynamic tolerance of intermittent hemodialysis in critically ill patients: usefulness of practice guidelines. Am J Respir Crit Care Med 162:197–202
    • View reference on publisher's website
    • View reference on PubMed
  27. Grams ME, Estrella MM, Coresh J, Brower RG, Liu KD (2011) Fluid balance, diuretic use, and mortality in acute kidney injury. Clin J Am Soc Nephrol 6:966–973
    • View reference on publisher's website
    • View reference on PubMed
  28. Teixeira C, Garzotto F, Piccinni P, Brienza N, Iannuzzi M, Gramaticopolo S, Forfori F, Pelaia P, Rocco M, Ronco C, Anello CB, Bove T, Carlini M, Michetti V, Cruz DN (2013) Fluid balance and urine volume are independent predictors of mortality in acute kidney injury. Crit Care 17:R14
    • View reference on publisher's website
    • View reference on PubMed
  29. Herrler T, Tischer A, Meyer A, Feiler S, Guba M, Nowak S, Rentsch M, Bartenstein P, Hacker M, Jauch KW (2010) The intrinsic renal compartment syndrome: new perspectives in kidney transplantation. Transplantation 89:40–46
    • View reference on publisher's website
    • View reference on PubMed
  30. Prowle JR, Echeverri JE, Ligabo EV, Ronco C, Bellomo R (2010) Fluid balance and acute kidney injury. Nat Rev Nephrol 6:107–115
    • View reference on publisher's website
    • View reference on PubMed
  31. Heung M, Wolfgram DF, Kommareddi M, Hu Y, Song PX, Ojo AO (2012) Fluid overload at initiation of renal replacement therapy is associated with lack of renal recovery in patients with acute kidney injury. Nephrol Dial Transplant 27:956–961
    • View reference on publisher's website
    • View reference on PubMed
  32. Stoneking LR, Winkler JP, DeLuca LA, Stolz U, Stutz A, Luman JC, Gaub M, Wolk DM, Fiorello AB, Denninghoff KR (2015) Physician documentation of sepsis syndrome is associated with more aggressive treatment. West J Emerg Med 16:401–407
    • View reference on publisher's website
    • View reference on PubMed
  33. Yang S, Eaton CB, Lu J, Lapane KL (2014) Application of marginal structural models in pharmacoepidemiologic studies: a systematic review. Pharmacoepidemiol Drug Saf 23:560–571
    • View reference on publisher's website
    • View reference on PubMed
  34. Jun M, Heerspink HJ, Ninomiya T, Gallagher M, Bellomo R, Myburgh J, Finfer S, Palevsky PM, Kellum JA, Perkovic V, Cass A (2010) Intensities of renal replacement therapy in acute kidney injury: a systematic review and meta-analysis. Clin J Am Soc Nephrol 5:956–963
    • View reference on publisher's website
    • View reference on PubMed
  35. Van Wert R, Friedrich JO, Scales DC, Wald R, Adhikari NK (2010) High-dose renal replacement therapy for acute kidney injury: systematic review and meta-analysis. Crit Care Med 38:1360–1369
    • View reference on publisher's website
    • View reference on PubMed
  36. Lyndon WD, Wille KM, Tolwani AJ (2012) Solute clearance in CRRT: prescribed dose versus actual delivered dose. Nephrol Dial Transplant 27:952–956
    • View reference on publisher's website
    • View reference on PubMed
  37. Jun M, Bellomo R, Cass A, Gallagher M, Lo S, Lee J (2014) Timing of renal replacement therapy and patient outcomes in the randomized evaluation of normal versus augmented level of replacement therapy study. Crit Care Med 42:1756–1765
    • View reference on publisher's website
    • View reference on PubMed
  38. Schetz M, Gunst J, De Vlieger G, Van den Berghe G (2015) Recovery from AKI in the critically ill: potential confounders in the evaluation. Intensive Care Med 41:1648–1657

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