Timing the initiation of renal replacement therapy for acute kidney injury in Canadian intensive care units: a multicentre observational study

Clark, Edward G.; Wald, Ron; Levin, Adeera; Bouchard, Josée; Adhikari, Neill K. J.; Hladunewich, Michelle A.; Richardson, Robert; James, Matthew T.; Walsh, Michael; House, Andrew A.; Moist, Louise; Stollery, Daniel; Burns, Karen E. A.; Friedrich, Jan O.; Barton, James C.; Lafrance, Jean‐Philippe; Pannu, Neesh; Bagshaw, Sean M.

doi:10.1007/s12630-012-9750-4

Cited by 32 publications

(31 citation statements)

References 40 publications

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“…Prior studies examining the initiation of dialysis for AKI have not generated consensus (13)(14)(15)(16)(17)(18)(19)(20)(21)(22). Significantly heterogenous, these studies fail to include an adequate nondialyzed control group.…”

Section: Discussionmentioning

confidence: 99%

Dialysis versus Nondialysis in Patients with AKI

Wilson

Yang

Machado

et al. 2014

Clinical Journal of the American Society of Nephrology

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Background and objectives The benefit of the initiation of dialysis for AKI may differ depending on patient factors, but, because of a lack of robust evidence, the decision to initiate dialysis for AKI remains subjective in many cases. Prior studies examining dialysis initiation for AKI have examined outcomes of dialyzed patients compared with other dialyzed patients with different characteristics. Without an adequate nondialyzed control group, these studies cannot provide information on the benefit of dialysis initiation. To determine which patients would benefit from initiation of dialysis for AKI, a propensity-matched cohort study was performed among a large population of patients with severe AKI.Design, setting, participants, & measurements Adults admitted to one of three acute care hospitals within the University of Pennsylvania Health System from January 1, 2004, to August 31, 2010, who subsequently developed severe AKI were included (n=6119). Of these, 602 received dialysis. Demographic, clinical, and laboratory variables were used to generate a time-varying propensity score representing the daily probability of initiation of dialysis for AKI. Not-yet-dialyzed patients were matched to each dialyzed patient according to day of AKI and propensity score. Proportional hazards analysis was used to compare time to all-cause mortality among dialyzed versus nondialyzed patients across a spectrum of prespecified variables.Results After propensity score matching, covariates were well balanced between the groups, and the overall hazard ratio for death in dialyzed versus nondialyzed patients was 1.01 (95% confidence interval, 0.85 to 1.21; P=0.89). Serum creatinine concentration modified the association between dialysis and survival, with a 20% (95% confidence interval, 9% to 30%) greater survival benefit from dialysis for each 1-mg/dl increase in serum creatinine concentration (P=0.001). This finding persisted after adjustment for markers of disease severity. Dialysis initiation was associated with more benefit than harm at a creatinine concentration$3.8 mg/dl.Conclusions Dialysis was associated with increased survival when initiated in patients with AKI who have a more elevated creatinine level but was associated with increased mortality when initiated in patients with lower creatinine concentrations.

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Section: Discussionmentioning

confidence: 99%

Dialysis versus Nondialysis in Patients with AKI

Wilson

Yang

Machado

et al. 2014

Clinical Journal of the American Society of Nephrology

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“…Broadly speaking, CRRT is almost exclusively applied to patients in the intensive care unit (ICU). However, 2 patient-level epidemiologic studies [1,2] , surveys of self-reported practice patterns [3,4] and several large case series [5,6] have documented large variation in clinical practice. In 1996, Mehta and Letteri [3] surveyed 2,000 nephrologists in the US and found that less than 25% of patients with acute renal failure were treated with CRRT.…”

Section: Introductionmentioning

confidence: 99%

Patient Selection and Timing of Continuous Renal Replacement Therapy

et al. 2016

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When and in whom to initiate continuous renal replacement therapy (CRRT) for acute kidney injury (AKI) remains a highly controversial topic with large practice variation around the world. Even within countries, practice variation exists and recommendations for clinical practice are not specific. In this article, we report the consensus recommendations for timing and patient selection for CRRT - the results of the 2016 Acute Disease Quality Initiative XVII conference on ‘precision CRRT'. We suggest that these recommendations could serve to develop the best clinical practice and standards of care for use of CRRT in patients with AKI. Finally, we identify and highlight the areas of ongoing uncertainty and propose an agenda for future research.

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“…In current practice, the initiation of RRT is sometimes very early (i.e. within the first 24 hr) [10], but may sometimes be delayed, whereby diuresis is stimulated with diuretics, and RRT is started only with the appearance of serious events, rather than following a proactive decision based on the severity of renal impairment [11]. Indeed, this attitude is justified by the possibility that appropriate early treatment of sepsis may limit the progression to renal failure [12].…”

Section: Introductionmentioning

confidence: 99%

Impact on mortality of the timing of renal replacement therapy in patients with severe acute kidney injury in septic shock: the IDEAL-ICU study (initiation of dialysis early versus delayed in the intensive care unit): study protocol for a randomized controlled trial

Barbar

Binquet

Monchi

et al. 2014

Trials

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BackgroundOne of the most dreaded complications of septic shock is acute kidney injury. It occurs in around 50% of patients, with a mortality rate of about 60% at 3 months. There is no consensus on the optimal time to initiate renal replacement therapy. Retrospective and observational studies suggest that early implementation of renal replacement therapy could improve the prognosis for these patients.Methods/designThis protocol summarizes the rationale and design of a randomized, controlled, multicenter trial investigating the effect of early versus delayed renal replacement therapy in patients with severe acute kidney injury in early septic shock. In total, 864 critically ill adults with septic shock and evidence of acute kidney injury, defined as the failure stage of the RIFLE classification, will be enrolled. The primary outcome is mortality at 90 days. Secondary outcomes include safety, number of days free of mechanical ventilation, number of days free of renal replacement therapy, intensive care length of stay, in-hospital length of stay, quality of life as evaluated by the EQ-5D and renal replacement therapy dependence at hospital discharge. The primary analysis will be intention to treat. Recruitment started in March 2012 and will be completed by March 2015.DiscussionThis protocol for a randomized controlled study investigating the impact of the timing of renal replacement therapy initiation should provide an answer to a key question for the management of patients with acute kidney injury in the context of septic shock, for whom the mortality rate remains close to 60% despite improved understanding of physiopathology and recent therapeutic advances.Trial registrationClinicalTrials.gov identifier NCT01682590, registered on 10 September 2012.

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Timing the initiation of renal replacement therapy for acute kidney injury in Canadian intensive care units: a multicentre observational study

Cited by 32 publications

References 40 publications

Dialysis versus Nondialysis in Patients with AKI

Dialysis versus Nondialysis in Patients with AKI

Patient Selection and Timing of Continuous Renal Replacement Therapy

Impact on mortality of the timing of renal replacement therapy in patients with severe acute kidney injury in septic shock: the IDEAL-ICU study (initiation of dialysis early versus delayed in the intensive care unit): study protocol for a randomized controlled trial

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