Debate: Intermittent Hemodialysis versus Continuous Kidney Replacement Therapy in the Critically Ill Patient: The Choice Should Be Evidence Based

Abstract

Kidney replacement therapy (KRT) plays a major role in the treatment of severe AKI. Intermittent hemodialysis (HD) and continuous KRT (CKRT) are the main modalities in critically ill patients with AKI. CKRT is the preferred modality in many countries because of its alleged superiority on both hemodynamic tolerance and on kidney function recovery. In fact, randomized controlled trials (RCTs) comparing the two modalities have not shown any actual benefit of one technique over the other on mortality, hemodynamics, or kidney function recovery. Those RCTs were conducted more than 15 years ago. Major progress was eventually made leading to much lower mortality rates in recent studies than in previous studies. In addition, those RCTs included a noticeable proportion of patients who could have recovered without ever receiving KRT, as demonstrated by several recent studies. In the absence of evidence of clinical superiority of one KRT modality, the choice must be addressed not only regarding clinical outcome but also resources and logistics. Conclusions of health technology assessments and study reports were heterogeneous and conflicting concerning cost-effectiveness of intermittent HD versus CKRT. All these considerations justify a reevaluation of the issue in new RCTs that take into account recent knowledge on KRT initiation and management. Pending results of such study, the choice should be guided mainly by organizational considerations in each unit and without condemning any modality in the absence of proof.

Global Scientific Trends in Continuous Renal Replacement Therapy from 2000 to 2023: A Bibliometric and Visual Analysis

“…However, the study’s conclusions should be interpreted cautiously given the marginal significance of the main finding and possible residual confounding. A further limitation of this study is that it only included patients who were in the early RRT group, but many patients in this group may not actually require RRT [179].…”

Debate: Intermittent Hemodialysis versus Continuous Kidney Replacement Therapy in the Critically Ill Patient: Moderator Commentary

“…The proponents arguing for the exclusive use of continuous therapies are Sean Bagshaw, Javier Neyra, Ashita Tolwani, and Ron Wald, 9 while Khalil Chaibi, Didier Dreyfuss, and Stéphane Gaudry make the case for using intermittent hemodialysis in the critical care setting. 10…”

“…The proponents arguing for the exclusive use of continuous therapies are Sean Bagshaw, Javier Neyra, Ashita Tolwani, and Ron Wald, 9 while Khalil Chaibi, Didier Dreyfuss, and Stéphane Gaudry make the case for using intermittent hemodialysis in the critical care setting. 10 The key argument made in favor of CKRT is that it can be applied with greater flexibility and precision than intermittent hemodialysis. Essentially, that the continuous nature of CKRT allows for slow but steady clearance of solute and metabolic waste, gradual removal of excess volume, and gradual correction of electrolyte and acidbase derangements while minimizing hemodynamic stress.…”