RRT in AKI: Start Early or Wait?

Liu, Kathleen D.; Palevsky, Paul M.

doi:10.2215/cjn.06690616

Cited by 12 publications

(4 citation statements)

References 27 publications

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“…The optimal timing of RRT in critically ill patients is uncertain. 30 , 31 , 32 , 33 However, in patients with ALF, Australian and New Zealand clinicians initiated therapy in the absence of conventional creatinine-based indications and, in most patients, before KDIGO AKI Stage 2 or the onset of even moderate acidaemia. Australian and New Zealand clinicians appear to use CRRT to target high ammonia levels because of their potential to contribute to cerebral oedema.…”

Section: Discussionmentioning

confidence: 99%

Continuous renal replacement therapy and its impact on hyperammonaemia in acute liver failure

Warrillow¹,

Fisher²,

Tibballs³

et al. 2020

Critical Care and Resuscitation

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Objective: Hyperammonaemia contributes to complications in acute liver failure (ALF) and may be treated with continuous renal replacement therapy (CRRT), but current practice is poorly understood. Design: We retrospectively analysed data for baseline characteristics, ammonia concentration, CRRT use, and outcomes in a cohort of Australian and New Zealand patients with ALF. Setting: All liver transplant ICUs across Australia and New Zealand. Participants: Sixty-two patients with ALF. Main outcome measures: Impact of CRRT on hyperammonaemia and patient outcomes. Results: We studied 62 patients with ALF. The median initial (first 24 h) peak ammonia was 132 mol/L (interquartile range [IQR], 91–172), median creatinine was 165 mol/L (IQR, 92–263) and median urea was 6.9 mmol/L (IQR, 3.1–12.0). Most patients (43/62, 69%) received CRRT within a median of 6 hours (IQR, 2–12) of ICU admission. At CRRT commencement, three-quarters of such patients did not have Stage 3 acute kidney injury (AKI): ten patients (23%) had no KDIGO creatinine criteria for AKI, 12 (28%) only had Stage 1, and ten patients (23%) had Stage 2 AKI. Compared with non-CRRT patients, those treated with CRRT had higher ammonia concentrations (median, 141 mol/L [IQR, 102–198] v 91 mol/L [IQR, 54–115]; P = 0.02), but a nadir Day 1 pH of only 7.25 (standard deviation, 0.16). Prevention of extreme hyperammonaemia (> 140 mol/L) after Day 1 was achieved in 36 of CRRT-treated patients (84%) and was associated with transplant-free survival (55% v 13%; P = 0.05). Conclusion: In Australian and New Zealand patients with ALF, CRRT is typically started early, before Stage 3 AKI or severe acidaemia, and in the presence hyperammonaemia. In these more severely ill patients, CRRT use was associated with prevention of extreme hyperammonaemia, which in turn, was associated with increased transplant-free survival.

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Section: Discussionmentioning

confidence: 99%

Continuous renal replacement therapy and its impact on hyperammonaemia in acute liver failure

Warrillow¹,

Fisher²,

Tibballs³

et al. 2020

Critical Care and Resuscitation

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“…Mortality difference was not observed before 90 days, and this difference had a very low (3 patients) fragility index. 4,5 A comparison of ELAIN with the HEROICS (Hemofiltration to Rescue Severe Shock Following Cardiac Surgery) trial 6 is much more appropriate. The latter was a multicenter randomized trial including 224 patients with severe shock after cardiac surgery and compared a "very early" with a standard RRT initiation strategy, as in ELAIN, but did not show an effect on mortality.…”

Section: And the Elain (Effect Of Early Vs Delayed Initiation Of Renamentioning

confidence: 99%

Why ELAIN and AKIKI Should Not Be Compared: Resolving Discordant Studies

Dreyfuss

Hajage

Gaudry

2017

American Journal of Kidney Diseases

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“…Furthermore, early initiation of RRT was associated with substantial decreases in the median duration of both RRT (−2 weeks) and hospital stay (−4 weeks), an astounding difference in a randomized trial in the ICU. These intriguing features were underlined in a recent editorial by Liu and Palevsky (14). The difference in mortality was not observed at 60 days, but rather at 90 days only, a finding that is difficult to explain in the ICU setting.…”

mentioning

confidence: 96%