Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients

Bellomo, Rinaldo; Cass, Alan; Cole, Louise; Finfer, Simon; Gallagher, Martin; Lo, Serigne; McArthur, Colin; Myburgh, John; Norton, Robyn; Scheinkestel, Carlos; Su, Steve

doi:10.1056/nejmoa0902413

Cited by 1,250 publications

(426 citation statements)

References 17 publications

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“…Some reasons for this difference might be the result of previous studies that focused on identifying the indications and timing of renal replacement therapy [11,12], CRRT modalities in critically ill patients [2,13], CRRT dose [14,15,16] and the impact of anticoagulation on filter life during CRRT [17,18]. Therefore, any reporting of haemodynamic changes at the time of initiation of CRRT may only be an incidental finding.…”

Section: Discussionmentioning

confidence: 99%

Haemodynamic Impact of a Slower Pump Speed at Start of Continuous Renal Replacement Therapy in Critically Ill Adults with Acute Kidney Injury: A Prospective Before-and-After Study

et al. 2011

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Background and Objective: Patients are at risk of haemodynamic instability when starting continuous renal replacement therapy (CRRT). Methods: We compared data for ‘routine-protocol’ pump speed increases of 50 ml/min over 1–4 min with ‘slower’ increases of 20–50 ml/min over 3–10 min to achieve an operating blood flow of 200 ml/min. Results: We studied 21 routine and 20 slower CRRT starts. ‘Routine protocol’ starts reached the target pump speed more quickly than the slower CRRT start (p < 0.05). Heart rate was higher in the routine group compared to the slower group at baseline (p < 0.01) and remained so throughout. There were no significant changes in central venous pressure or mean arterial pressure, and no episodes of hypotension or hypertension, in either group, or in the subset of 17 CRRT starts in vasopressor-dependent patients. Conclusion: We cannot recommend a slower pump speed start based on our findings, but advocate for close haemodynamic monitoring, as haemodynamic changes in individual patients cannot be predicted in advance.

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Section: Discussionmentioning

confidence: 99%

Haemodynamic Impact of a Slower Pump Speed at Start of Continuous Renal Replacement Therapy in Critically Ill Adults with Acute Kidney Injury: A Prospective Before-and-After Study

et al. 2011

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“…The Acute Renal Failure Trial Network (ARFTN) study demonstrated that there is no benefit of intermittent haemodialysis six times a week vs three times a week or CVVHDF at a dose of 35 ml/kg/h vs 20 ml/kg/h [26]. Similarly The Randomized Evaluation of Normal versus Augmented Level (RENAL) replacement therapy study failed to show any advantage of 40 ml/kg/h CVVHDF vs 20 ml/kg/h [27].…”

Section: Dose Of Rrtmentioning

confidence: 99%

Acute kidney injury in sepsis

Wijayaratne

Wijewickrama

2017

Sri Lanka j Surg

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Sepsis is life-threatening organ dysfunction resulting from a dysregulated host response to infection. It is one of the commonest causes of acute kidney injury (AKI) and is associated with an increase in both morbidity and mortality. Both haemodynamic and non-haemodynamic factors are involved in the pathogenesis of AKI in sepsis. Newer tests are available for the early diagnosis of AKI in septic patients and may provide an opportunity for prevention. The current mainstay of prevention is adequate fluid resuscitation and maintenance of systemic blood pressure, noradrenaline being the vasopressor of choice. Renal replacement therapy may improve outcomes. Continuous renal replacement modalities are preferred in those who are haemodynamically unstable. There is no consensus on the optimal timing or dose of renal replacement therapy.

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“…Whether the same applies for a dose of 35 ml/kg/h remains to be answered. In the recent Randomized Evaluation of Normal versus Augmented Level (RENAL) study [10], 1,508 critically ill patients with AKI were randomized to receive a CVVHDF dose of either 25 or 40 ml/kg/h. No difference in 90-day mortality, the primary endpoint of the study, was observed between the two groups.…”

Section: Update On Recent Negative Trials In Aki In Critically Ill Pamentioning

confidence: 99%

“…Moreover, mortality in sepsis-induced AKI is significantly higher than in non-septic AKI [4,5,6]. While several milestone studies in the last decade [7,8] have shown that the dose of therapy was of paramount importance regarding mortality, more recent trials have challenged this concept [9,10]. It stands to reason that a critical minimum dose is still desirable and that below this defined dose, mortality will be affected [11,12].…”

Section: Introductionmentioning

confidence: 99%

New Insights Regarding Rationale, Therapeutic Target and Dose of Hemofiltration and Hybrid Therapies in Septic Acute Kidney Injury

et al. 2011

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Mediator removal from tissue (capillary blood compartment, CABC) and transport to the central circulation (central blood compartment, CEBC) must be effective. Effectiveness through a passive mechanism seems unlikely as the surface of CEBC (30 m²) is smaller than CABC (300 m²) whereby the former will be a limiting factor in passive transport. According to studies, a high exchange volume can induce an 80-fold increase in lymphatic flow. This results in displacement (active transport) of mediators to CEBC. Recent studies have shown that the delivered dose constitutes the mainstay of continuous renal replacement therapy. However, these results are not likely to change the recommendation: 35 ml/kg/h, adjusted for predilution, in septic acute kidney injury (AKI). Recently, studies were focusing on global intensive care unit AKI. In non-septic AKI, those studies show that 20–25 ml/kg/h was optimal. The DO-RE-MI trial underscored the importance of delivery which could be obtained by targeting doses between 5 and 10 ml/kg/h higher than prescribed. Until the IVOIRE trial becomes available, septic AKI should be treated by continuous veno-venous hemofiltration at 35 ml/kg/h. In non-septic AKI, 25 ml/kg/h remains optimal.

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Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients

Abstract: In critically ill patients with acute kidney injury, treatment with higher-intensity continuous renal-replacement therapy did not reduce mortality at 90 days. (ClinicalTrials.gov number, NCT00221013.)

Cited by 1,250 publications

References 17 publications

Haemodynamic Impact of a Slower Pump Speed at Start of Continuous Renal Replacement Therapy in Critically Ill Adults with Acute Kidney Injury: A Prospective Before-and-After Study

Haemodynamic Impact of a Slower Pump Speed at Start of Continuous Renal Replacement Therapy in Critically Ill Adults with Acute Kidney Injury: A Prospective Before-and-After Study

Acute kidney injury in sepsis

New Insights Regarding Rationale, Therapeutic Target and Dose of Hemofiltration and Hybrid Therapies in Septic Acute Kidney Injury

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