Intermittent Convective Therapies in Patients with Acute Kidney Injury: A Systematic Review with Meta-Analysis

Abstract

<b><i>Introduction:</i></b> In critically ill patients requiring intermittent renal replacement therapy (RRT), the benefits of convective versus diffusive clearance remain uncertain. We conducted a systematic review and meta-analysis to determine the safety, clinical efficacy, and clearance efficiency of hemofiltration (HF) and hemodiafiltration (HDF) compared to hemodialysis (HD) in patients with acute kidney injury (AKI) receiving intermittent RRT. <b><i>Method:</i></b> We searched Medline, Embase, Cochrane Library, and PROSPERO. We included clinical trials and observational studies that reported the use of intermittent HF or HDF in adult patients with AKI. The following outcomes were included: mortality, renal recovery, clearance efficacy, intradialytic hemodynamic stability, circuit loss, and inflammation modulation. <b><i>Results:</i></b> A total of 3,169 studies were retrieved and screened. Four randomized controlled trials and 4 observational studies were included (<i>n</i>: 615 patients). Compared with conventional HD, intermittent convective therapies had no effect on in-hospital mortality (relative risk, 1.23; 95% confidence interval (CI), 0.76–1.99), renal recovery at 30 days (RR, 0.98; 95% CI, 0.82–1.16), time-to-renal recovery (mean difference [MD], 0.77; 95% CI, −6.56 to 8.10), and number of dialysis sessions until renal recovery (MD, −1.34; 95% CI, −3.39 to 0.72). The overall quality of included studies was low, and dialysis parameters were suboptimal for all included studies. <b><i>Conclusion:</i></b> This meta-analysis suggests that there is no significant difference in short-term mortality and renal recovery in patients with severe AKI when treated with intermittent HF or HDF compared to conventional HD. This systematic review emphasizes the need for further trials evaluating optimal convective parameters in AKI patients treated with intermittent dialysis.

Online Hemodiafiltration Compared to Conventional Hemodialysis in Critically Ill Patients

“… 31 , 32 In contrast, the possibility to perform high volumes of convective clearance using IRRT is more recent with the development of online HDF. In a recent meta-analysis comparing conventional HD to intermittent convective therapies, 15 we reported that only 3 small scale exploratory trials ever compared HD to HDF. 33 , 34 , 35 Most interestingly, pooling the results of these trials revealed a higher risk of in-hospital death with the use of HDF (Risk ratio: 2.07 CI: 1.04–4.11).…”

“…33 , 34 , 35 Most interestingly, pooling the results of these trials revealed a higher risk of in-hospital death with the use of HDF (Risk ratio: 2.07 CI: 1.04–4.11). 15 Therefore, further investigation was urgently required to determine the safety and potential benefits of HDF in an ICU setting. In this cohort, we did not observe an increased risk of death with the use of HDF.…”

“… 45 , 46 , 47 When adjusted to achieve high convective volumes, HDF tends to improve inflammatory status when compared to HD in maintenance dialysis. 15 …”

“…A recent meta-analysis emphasized the need for further studies evaluating the impact of convective IRRT modalities in the ICU. 15 …”

Renal Replacement Therapies in the Intensive Care Unit

“…This modality is named hemodiafiltration (HDF), requires an adapted dialysis machine, and is increasingly used in Europe and Asia for ESRD patients. However, its implementation in ICU settings remains limited, partly due to the need to maintain a water treatment system adapted to HDF [8]. As a result, when reporting intermittent RRT in the ICU, we generally consider only IHD.…”