© 2008 Universitair Ziekenhuis Gent RENAL REPLACEMENT THERAPY IN PATIENTS WITH SEPSIS AND ACUTE...

© 2008 Universitair Ziekenhuis Gent

RENAL REPLACEMENT THERAPY IN PATIENTS WITH SEPSIS AND ACUTE KIDNEY INJURY

Prof. Dr. Raymond Vanholder

University Hospital Ghent

Belgium

22© 2008 Universitair Ziekenhuis Gent

TIMING START RRT

TYPE OF STUDY N PARAMETER EFFECT ES

Gettings et al, 1999 Retrospective 243 BUN 76 +

Guerin et al, 2000 Prospective

Observational post hoc

510 Time after admission 0

Bouman et al, 2002 RCT*, 4 arms 106 Fixed time point (12 hrs) vs. classical parameters

0

Elahi et al, 2004 Retrospective 64 UO vs. other** +

Demirkiliç et al, 2004 Retrospective 61 UO vs. other** +

Liu et al, 2006 Observational 243 BUN 76 0 unadj

+ adj

Piccinni et al, 2006 Retrospective 80 Septic shock +

ES: Early Start; BUN: Blood Urea Nitrogen; UO: urine output; + favors ES; 0 neutral*: early vs. late low vol (<36 L/d) HF – early high vol(>72L/d) no late comparator; **: UO <100 mL/d to start vs. other parameters (K, crea) irrespective of UOGettings et al, Intens Care Med, 1999; Guerin et al, Am J Resp CCM, 2000; Bouman et al, CCM, 2002; Elahi et al, Eur J Cardio-thor Surg, 2004; Demirkiliç et al, J Card Surg, 2004; Liu et al, Clin JASN 2006 ; Piccinni et al, Intens Care Med 2006


C. Bouman, Crit Care Med, 30: 2205-2211; 2002

Effects of early high-volume continuous venovenous hemofiltration on survival and recovery of renal function in intensive care patients with acute renal failure: A prospective, randomized trial

Bouman, Catherine S. C. MD; Oudemans-van Straaten, Heleen M. MD, PhD; Tijssen, Jan G. P. MD, PhD; Zandstra, Durk F. MD, PhD; Kesecioglu, Jozef MD, PhD

From the Departments of Intensive Care (CSCB) and Clinical Epidemiology (JGPT), Academic Medical Center, Amsterdam, The Netherlands; the Department of Anesthesiology, Cardiothoracic and Neurosurgical Intensive Care Unit, University Medical Center, Utrecht, The Netherlands (JK); and the Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands (HMOvS, DFZ).Address requests for reprints to: Catherine S. C. Bouman, MD, Academic Medical Center, Department of Intensive Care, Meibergdreef 9, Amsterdam NL-1105 AZ, The Netherlands. E-mail: [email protected]


V. Seabra et al, AJKD, 52: 272-284; 2008


IMPACT ON MORTALITY




IMPACT ON RECOVERY RENAL FUNCTION



ABSTRACTBackground Some studies have suggested that early institution of renal replacement therapy (RRT) might be associated with improved outcomes in patients with acute renal failure (ARF).Study Design A systematic review and meta-analysis of randomized controlled trials and cohort comparative studies to assess the effect of early RRT on mortality in patients with ARF.Setting & Population Hospitalized adult patients with ARF.Selection Criteria for Studies We searched several databases for studies that compared the effect of “early” and “late” RRT initiation on mortality in patients with ARF. We included studies of various designs.Intervention Early RRT as defined in the individual studies.Outcomes The primary outcome measure was the effect of early RRT on mortality stratified by study design. The pooled risk ratio (RR) for mortality was compiled using a random-effects model. Heterogeneity was evaluated by means of subgroup analysis and meta-regression.Results We identified 23 studies (5 randomized or quasi-randomized controlled trials, 1 prospective and 16 retrospective comparative cohort studies, and 1 single-arm study with a historic control group). By using meta-analysis of randomized trials, early RRT was associated with a nonsignificant 36% mortality risk reduction (RR, 0.64; 95% confidence interval, 0.40 to 1.05; P = 0.08). Conversely, in cohort studies, early RRT was associated with a statistically significant 28% mortality risk reduction (RR, 0.72; 95% confidence interval, 0.64 to 0.82; P < 0.001). The overall test for heterogeneity among cohort studies was significant (P = 0.005). Meta-regression yielded no significant associations; however, early dialysis therapy was associated more strongly with lower mortality in smaller studies (n < 100) by means of subgroup analysis.Limitations Paucity of randomized controlled trials, use of variable definitions of early RRT, and publication bias preclude definitive conclusions.Conclusion This hypothesis-generating meta-analysis suggests that early initiation of RRT in patients with ARF might be associated with improved survival, calling for an adequately powered randomized controlled trial to address this question.


Vinsonneau et al, Lancet, 368, 379-385, 2006


MOST RECENT STUDIES

IHD CVVHD P

Survival

Day 28 41.8% 38.9% 0.65

Day 60 (1ary EP) 32.5% 32.6% 0.98

Day 90 27.2% 28.5% 0.95

RRT duration (d) 11 11 0.84

Length ICU stay (d) 20 19 0.73

Length hosp stay (d) 30 32 0.66

Vinsonneau et al, Lancet, 368, 379-385, 2006


R. L. Lins et al, NDT, advance access published October 14, 2008


R. L. Lins et al, NDT, advance access published October 14, 2008

THE SHARF STUDY

1212© 2008 Universitair Ziekenhuis Gent Bagshaw et al, Crit Care Med, 36: 610-617; 2008

Continuous versus intermittent renal replacement therapy for critically ill patients with acute kidney injury: A meta-analysis

Bagshaw, Sean M. MD, MSc; Berthiaume, Luc R. MD; Delaney, Anthony MBBS, MSc; Bellomo, Rinaldo MD

From the Division of Critical Care Medicine, University of Alberta Hospital, University of Alberta, Edmonton, Alberta, Canada (SMB); Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia (SMB, RB); Departments of Critical Care Medicine and Community Health Sciences, Calgary Health Region and University of Calgary, Calgary, Alberta, Canada (LRB); and Intensive Care Unit, Royal North Shore Hospital, and Northern Clinical School, University of Sydney, Sydney, NSW, Australia (AD).


W. Van Biesen et al, Crit Care Med, 36: 649-650; 2008

A tantalizing question: Ferrari or Rolls Royce? A meta-analysis on the ideal renal replacement modality for acute kidney injury at the intensive care unit

Van Biesen, Wim MD, PhD; Lameire, Norbert MD, PhD; Vanholder, Raymond MD, PhD

Renal Division; Department of Internal Medicine; University Hospital Ghent; Ghent, Belgium


FACTORS AFFECTING CHOICE

Labor intensity

Cost

Availability of machines

Availability of SLEDD as alternative


Extended Daily Dialysis: what?

Offering the choice between the advantages of a IHDF-monitor (high efficiency, low cost, high precision of UF control) in combination with the advantages of CRRT (extended treatment, smooth metabolic control) in a modular fashion, using one single type of dialysis machine

Dialysis monitor with:Water treatment moduleReverse osmosis unitHemofiltration capacityDialysate flow adjustment


TOTAL NUMBER, DURATION, AND MEDIAN NUMBER OF TREATMENTS PERFORMED

EDD CVVH

Total no of treatment days

367 113

Median duration daily treatment(h)

7.5 (6-8) 19.5 (13.4-24)

Median no of treatments/patient

9 (3-39) 6 (3-15)

Kumar et al. Am J Kidney Dis 36:294-300,2000


COMPARISON OF MAP DURING EDD VS. CVVH.

0102030405060708090

100

preMAP midMAP endMAP

CVVH

EDD

Kumar et al, AJKD, 36, 294-300, 2000

P=NS P=NS P=NS


PERCENTAGE OF TREATMENT DAYS REQUIRING INOTROPIC SUPPORT

0

10

20

30

40

50

60

70

80

90

100

1 Inotrope 2 Inotropes 3+ Inotropes

CVVH

EDD

% o

f tr

ea

tme

nt

da

ys

Kumar et al, AJKD, 36, 294-300, 2000


SINGLE PASS BATCH HEMODIALYSIS SYSTEM (GENIUS): PREPARATION OF DIALYSIS WATER AND DIALYSATE


CUMULATIVE ULTRAFILTRATION VOLUME AND MEAN ARTERIAL PRESSURE DURING 18H OF EXTENDED HIGH-FLUX HD USING THE GENIUS SYSTEM

Lonnemann et al, NDT, 15, 1189-1193, 2000


R. Busund et al, Int Care Med, 28: 1434-1439; 2002

PF: signif younger &less mechanicalventilation


J. Tumlin et al, JASN, 19: 1034-1040; 2008


Schiffl et al, NEJM, 346: 305-310; 2002


P. Honore et al, Crit Care Med, 28: 3581-3587; 2000

Prospective evaluation of short-term, high-volume isovolemic hemofiltration on the hemodynamic course and outcome in patients with intractable circulatory failure resulting from septic shock

Honore, Patrick, Jamez, Jean, Wauthier, Michel, Lee, Patrice, Dugernier, Thierry, Pirenne, Bruno, Hanique, Genevieve, Matson, James

From the Departments of Intensive Care Medicine (Drs. Honore, Dugernier, and Pirenne) and Nephrology (Drs. Jamez and Wauthier), St-Pierre Hospital, Ottignies, Belgium; the Department of Clinical Research and Pediatric Critical Care (Drs. Lee and Matson), Dallas Hospital, Dallas, TX; and the Department of Internal Medicine and Biostatistics (Dr. Hanique), Nivelles Hospital, Nivelles, Belgium


C. Ronco et al, The Lancet, 256: 26-30; 2000


P. Saudan et al, KI, 70: 1312-1317; 70


C. Bouman, Crit Care Med, 30: 2205-2211; 2002

Effects of early high-volume continuous venovenous hemofiltration on survival and recovery of renal function in intensive care patients with acute renal failure: A prospective, randomized trial

Bouman, Catherine S. C. MD; Oudemans-van Straaten, Heleen M. MD, PhD; Tijssen, Jan G. P. MD, PhD; Zandstra, Durk F. MD, PhD; Kesecioglu, Jozef MD, PhD

From the Departments of Intensive Care (CSCB) and Clinical Epidemiology (JGPT), Academic Medical Center, Amsterdam, The Netherlands; the Department of Anesthesiology, Cardiothoracic and Neurosurgical Intensive Care Unit, University Medical Center, Utrecht, The Netherlands (JK); and the Department of Intensive Care, Onze Lieve Vrouwe Gasthuis, Amsterdam, The Netherlands (HMOvS, DFZ).Address requests for reprints to: Catherine S. C. Bouman, MD, Academic Medical Center, Department of Intensive Care, Meibergdreef 9, Amsterdam NL-1105 AZ, The Netherlands. E-mail: [email protected]


Palevsky et al, NEJM, 359, 1: 7-20; 2008

Intensive vs less intensive therapy

Intermittent hemodialysis (hemodynamically stable)

Intensive: daily except Sunday

Less intensive: alternate days except Sunday

Sustained low-efficiency dialysis (hemodynamically unstable)

Intensive: daily except Sunday

Less intensive: alternate days except Sunday

Continuous renal replacement therapy (hemodynamically unstable)

Intensive: 35 mL/h/kgBW substitution

Less intensive: 20 mL/h/kgBW substitution


Palevsky et al, NEJM, 359, 1: 7-20; 2008

KAPLAN–MEIER PLOT OF CUMULATIVE PROBABILITIES OF DEATH CUMULATIVE PROBABILITY OF DEATH FROM ANY CAUSE IN THE ENTIRE STUDY COHORT


COMMENTS

Standard IHD more efficient than in Schiffl et al

Hemodiafiltration

Shifts among therapies possible

Kt/V not a validated parameter of adequacy in AKI

More adequate treatment may also have negative impact

REAL-LIFE STUDIES


SINGLE PASS BATCH HEMODIALYSIS SYSTEM (GENIUS): PREPARATION OF DIALYSIS WATER AND DIALYSATE


GENIUSR

S. Eloot et al, NDT, 22: 2962-2969; 2007


PERCENTAGE CHANGE VS. 4 HRS

Eloot et al, KI, 73: 765-770


COMMENTS


Hemodiafiltration




REAL-LIFE STUDIES


ANTIBIOTIC CONCENTRATION AND SLEDD

Kielstein et al, NDT, in press

MIC 90


PRACTICE PATTERNS IN THE MANAGEMENT OF ACUTE RENAL FAILURE IN THE CRITICALLY ILL PATIENT: AN INTERNATIONAL SURVEY

RICCI et al. Nephrol Dial Transpl, 21: 690–696, 2006


COMMENTS


Hemodiafiltration




REAL-LIFE STUDIES


CONCLUSIONS

At this moment, there are no definite data favoring an earlier start of RRT than the conventional criteria

There is no difference in outcome between intermittent an continuous dialysis strategies

Although under well controlled circumstances, intensified strategies seem to improve outcome, under real life circumstances this difference seems to disappear

© 2008 Universitair Ziekenhuis Gent RENAL REPLACEMENT THERAPY IN PATIENTS WITH SEPSIS AND ACUTE...

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