Early High-Volume Hemofiltration versus Standard Care for Post–Cardiac Surgery Shock. The HEROICS Study

Combes, Alain; Bréchot, Nicolas; Amour, Julien; Cozic, Nathalie; Lebreton, Guillaume; Guidon, C.; Zogheib, Élie; Thiranos, J.-C.; Rigal, Jean-Christophe; Bastien, Olivier; Benhaoua, Hamina; Abry, B.; Ouattara, Alexandre; Trouillet, Jean‐Louis; Mallet, Alain; Chastre, Jean; Leprince, Pascal; Luyt, Charles‐Édouard

doi:10.1164/rccm.201503-0516oc

Cited by 109 publications

(159 citation statements)

References 51 publications

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“…Several studies have examined the timing of RRT initiation in AKI patients in the ICU. It is unclear whether the early initiation of RRT improves survival and renal recovery rates [4][5][6][7][8][9]. These studies, however, differ in their definition of early and late initiation.…”

Section: Reviewmentioning

confidence: 99%

“…Until recently, three randomized controlled trials (RCTs) evaluated whether the early initiation of RRT improved mortality in patients with AKI [4,5,9]. In one study, Bourman et al randomized 106 critically ill patients with AKI into three groups, 35 were treated with early high-volume HF (HVHF), 35 with early low-volume HF, and 36 with late low-volume HF [4].…”

Section: Reviewmentioning

confidence: 99%

“…Patients were randomized to an early-start group, receiving RRT when urine volume was <30 mL/h for 3 h, or conventional-start group who waited to receive RRT until urine volume was <20 mL/h for 2 h. Early RRT significantly improved patient survival (p < 0.01), indicating that the timing of RRT initiation in post-cardiac surgery patients with AKI should be determined by urine volume not by SCr levels. In the HEROICS trial, 224 patients with severe shock requiring high-dose catecholamines following cardiac surgery were randomized to early HVHF (80 mL/kg/h) for 48 h followed by standard-volume continuous veno-venous hemodiafiltration (CVVHDF) (n = 112) or to standard care with delayed CVVHDF (n = 112) [9]. Patients in the latter group received CVVHDF when SCr was >354 μmol/L (>4 mg/dL) or had increased threefold from preoperative levels; when urine output was <0.3 mL/kg/h for 24 h; when urea was >36 mmol/L; or when they experienced life-threatening hyperkalemia.…”

Section: Reviewmentioning

confidence: 99%

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Renal replacement therapy for acute kidney injury

et al. 2016

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The annual incidence of acute kidney injury (AKI) has been increasing as the population ages. Despite advances in critical care and dialysis technology, the mortality remains unacceptably high in patients with AKI during the past few decades. Renal replacement therapy (RRT) is performed to treat patients with severe AKI and multiple organ failures, as well as to remove fluid in patients with fluid overload including those with acute heart failure and lung edema in the intensive care unit (ICU). The mortality in patients with AKI requiring RRT is higher than 50 %. RRT strategies in patients with AKI depend on various conditions. However, there is little consensus on when to start and stop RRT, its optimal dose, and the choice of different RRT modalities (intermittent versus (vs.) continuous) in patients with AKI. Patients with AKI in the ICU are preferentially treated with continuous rather than intermittent RRT (IRRT), usually because of hemodynamic stability and steady of solute clearance. At present, the type and dose of RRT are dependent on the experience of the attending clinicians, including intensivists and nephrologists.

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Section: Reviewmentioning

confidence: 99%

Section: Reviewmentioning

confidence: 99%

Section: Reviewmentioning

confidence: 99%

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Renal replacement therapy for acute kidney injury

et al. 2016

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“…In line with the negative results of the IVOIRE trial, Quenot et al found no benefit of the CASCADE technique, allowing very high volume hemofiltration, in a pilot study randomizing 60 patients [17], while Combes et al found no benefit of high volume hemofiltration randomizing 224 patients with postcardiac surgery shock [18]. Finally, Payen and colleagues found no benefit of polymyxin (PMX) hemoperfusion in 232 adult postoperative patients with documented peritonitis and septic shock [19].…”

Section: Extracorporeal Blood Purificationmentioning

confidence: 95%

Focus on acute kidney injury and fluids

2016

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An acute deterioration of kidney function, currently known as acute kidney injury (AKI), frequently develops in ICU patients and is always bad news. In this overview we will highlight recent findings related to its diagnosis, epidemiology, and extracorporeal treatment. Epidemiology of AKIThe AKI-EPI study, a worldwide cross-sectional study on the occurrence of acute kidney injury (AKI) in the first week in intensive care unit (ICU), found AKI in 57 % of the 1800 included patients. AKI severity was associated with adverse patient and kidney outcome at hospital discharge [1]. Analysis of a large cohort (32,045) in a single medical center confirmed the high prevalence (74.5 %) and further illustrated that both AKI severity and duration and the criteria used to define it (creatinine, urine output, or both) had significant impact on short-and long-term outcomes [2]. Another large cohort study in 580 patients with out-of-hospital cardiac arrest found severe AKI in 43 % of the patients and the association with mortality but not with neurological outcome [3]. Last, it must be noted that first validation of the Kidney Disease Improving Global Outcomes (KDIGO) criteria was performed in a large pediatric population [4]. Assessment of renal prognosis and of renal functionSeveral studies demonstrated limits of usual renal dysfunction criteria and of biomarkers in assessing renal function or predicting renal prognosis. First, short episodes of oliguria in ICU patients are frequent and do not always predict subsequent AKI by creatinine criteria. Legrand et al. explored whether AKI biomarkers could predict worsening of kidney function (WKF) in 111 critically ill patients with first episode of oliguria. Interestingly, although plasma neutrophil gelatinase-associated lipocalin (NGAL) might improve the prediction of WKF, the biomarker had a similar performance to serum creatinine [5]. Furthermore, the follow-up of the furosemide stress test study found limited performance of biomarkers to predict WKF, which were largely outperformed by the furosemide stress test [6].The gold standard for glomerular filtration rate (GFR) determination is inulin clearance, but this cannot be measured easily. Carlier and co-workers compared inulin clearance with creatinine clearance and several creatinine and/or cystatin C-based GFR equations in 68 critically ill patients with stable kidney function. As a result of tubular secretion of creatinine, measured creatinine clearance resulted in a slight overestimation of GFR while creatinine-based equations had the worst performance with overestimation of the true GFR; the overestimation increased with hospital stay [7]. This confirms previous findings showing increasing differences between discharge estimated GFR (eGFR) and creatinine clearance with increasing ICU stay in both AKI and non-AKI patients. Reduced creatinine excretion resulting from muscle loss was the main determinant of this difference [8]. Since cystatin is not influenced by muscle mass, the cystatin-based equations did not share the hospi...

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“…For example, the timing of RRT initiation in the ELAIN Trial is most similar to that in the High Volume Venovenous Hemofiltration Versus Standard Care for Post-Cardiac Surgery Shock (HEROICS) Trial, but the results are discordant. The HEROICS Trial was a multicenter, randomized trial of 224 patients with severe shock requiring high-dose catecholamine infusion after cardiac surgery that compared a strategy of 48 hours of HVHF initiated within 3-24 hours of surgery followed by conventional CVVHDF with standard care, in which CVVHDF was provided only for stage 3 AKI, a BUN.100 mg/dl, or life-threatening hyperkalemia (23). 111 of 112 patients in the early HVHF arm initiated RRT within 24 hours of surgery, whereas 64 of 112 patients in the conventional CVVHDF arm initiated RRT after a mean of 1.563.4 days.…”

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confidence: 99%