Early renal replacement therapy (RRT) initiation should theoretically influence many physiological disorders related to acute kidney injury (AKI). Currently, there is no consensus about RRT timing in intensive care unit (ICU) patients.
Methods
We performed a retrospective analysis of all critically ill patients who received RRT in our ICU during a 3 year-period. Our goal was to identify mortality risk factors and if RRT initiation timing had an impact on survival. RRT timing was calculated from the moment the patient was classified as having acute kidney injury in the RIFLE classification.
Results
A hundred and ten patients received RRT. We identified four independent mortality risk factors: need for mechanical ventilation (OR = 12.82 (1.305 - 125.868, p = 0.0286); RRT initiation timing >16 h (OR = 5.66 (1.954 - 16.351), p = 0.0014); urine output on admission <500 ml/day (OR = 4.52 (1.666 - 12.251), p = 0.003); and SAPS II on admission >70 (OR = 3.45 (1.216 - 9.815), p = 0.02). The RRT initiation <16 h and RRT initiation >16 h groups presented the same baseline characteristics, except for more severe gravity scores and kidney failure in the early RRT group.
Conclusions
Early RRT in ICU patients with acute kidney injury or failure was associated with increased survival.
BagshawS.M., GeorgeC., BellomoR.. ANZICS Database Management Committee. Changes in the incidence and outcome for early acute kidney injury in a cohort of Australian intensive care units.Crit Care.2007; 11(3): R68.
2.
LameireN., Van BiesenW., VanholderR.. Acute renal failure.Lancet.2005; 365(9457): 417–430.
3.
UchinoS., KellumJ.A., BellomoR.Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) Investigators. Acute renal failure in critically ill patients: a multinational, multicenter study.JAMA.2005; 294(7): 813–818.
4.
MetnitzP.G., KrennC.G., SteltzerH.Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients.Crit Care Med.2002; 30(9): 2051–2058.
5.
BellomoR., KellumJ., RoncoC.. Acute renal failure: time for consensus.Intensive Care Med.2001; 27(11): 1685–1688.
6.
BellomoR., RoncoC., KellumJ.A., MehtaR.L., PalevskyP.. Acute Dialysis Quality Initiative workgroup. Acute renal failure - definition, outcome measures, animal models, fluid therapy and information technology needs: the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group.Crit Care.2004; 8: R204–R212.
7.
MehtaR.L., KellumJ.A., ShahS.V.Acute Kidney Injury Network (AKIN): report of an initiative to improve outcomes in acute kidney injury.Crit Care2007; 11(2): R31.
8.
BrochardL., AbrougF., BrennerM.ATS/ERS/ESICM/SCCM/SRLF Ad Hoc Committee on Acute Renal Failure. An Official ATS/ERS/ESICM/SCCM/SRLF Statement: Prevention and Management of Acute Renal Failure in the ICU Patient: an international consensus conference in intensive care medicine.Am J Respir Crit Care Med.2010; 181(10): 1128–1155.
9.
RoncoC., BellomoR., HomelP.Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomised trial.Lancet.2000; 356(9223): 26–30.
10.
VA/NIH Acute Renal Failure Trial Network, PalevskyP.M., ZhangJ.H.Intensity of renal support in critically ill patients with acute kidney injury.N Engl J Med.2008; 359(1): 7–20.
11.
RENAL Replacement Therapy Study Investigators, BellomoR., CassA.Intensity of continuous renal-replacement therapy in critically ill patients.N Engl J Med.2009; 361(17): 1627–1638.
12.
GettingsL.G., ReynoldsH.N., ScaleaT.. Outcome in post-traumatic acute renal failure when continuous renal replacement therapy is applied early vs. late.Intensive Care Med.1999; 25(8): 805–813.
13.
LiuK.D., HimmelfarbJ., PaganiniE.Timing of initiation of dialysis in critically ill patients with acute kidney injury.Clin J Am Soc Nephrol.2006; 1(5): 915–919.
14.
BoumanC.S., Oudemans-Van StraatenH.M., TijssenJ.G., ZandstraD.F., KeseciogluJ.. 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.Crit Care Med.2002; 30(10): 2205–2211.
15.
BagshawS.M., UchinoS., BellomoR.Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) Investigators. Timing of renal replacement therapy and clinical outcomes in critically ill patients with severe acute kidney injury.J Crit Care.2009; 24(1): 129–140.
16.
BagshawS.M., LauplandK.B., DoigC.J.Prognosis for long-term survival and renal recovery in critically ill patients with severe acute renal failure: a population-based study.Crit Care.2005; 9(6): R700–R709.
17.
MehtaR.L., PascualM.T., GrutaC.G., ZhuangS., ChertowG.M.. Refining predictive models in critically ill patients with acute renal failure.J Am Soc Nephrol.2002; 13(5): 1350–1357.
18.
PaganiniE.P., LariveB., KanagasundaramN.S.. Severity scores and outcomes with acute renal failure in the ICU setting.Contrib Nephrol.2001; (132): 181–195.
19.
CerdáJ., CerdáM., KilcullenP., PrendergastJ.. In severe acute kidney injury, a higher serum creatinine is paradoxically associated with better patient survival.Nephrol Dial Transplant.2007; 22(10): 2781–2784.
20.
ElahiM.M., LimM.Y., JosephR.N., DhannapuneniR.R., SpytT.J.. Early hemofiltration improves survival in post-cardiotomy patients with acute renal failure.Eur J Cardiothorac Surg.2004; 26(5): 1027–1031.
21.
DemirkiliçU., KuralayE., YenicesuM.Timing of replacement therapy for acute renal failure after cardiac surgery.J Card Surg.2004; 19(1): 17–20.
22.
BentP., TanH.K., BellomoR.Early and intensive continuous hemofiltration for severe renal failure after cardiac surgery.Ann Thorac Surg.2001; 71(3): 832–837.
KarvellasC.J., FarhatM.R., SajjadI.A comparison of early versus late initiation of renal replacement therapy in critically ill patients with acute kidney injury: a systematic review and meta-analysis.Crit Care.2011; 15(1): R72.
25.
MacedoE., MehtaR.L.. When should renal replacement therapy be initiated for acute kidney injury?Semin Dial.2011; 24(2): 132–137.
26.
BoneR.C., FisherC.J., ClemmerT.P., SlotmanG.J., MetzC.A., BalkR.A.. Sepsis syndrome: a valid clinical entity.Crit Care Med.1989; 17(5): 389–393.
27.
LevyM.M., FinkM.P., MarshallJ.C.SCCM/ESICM/ACCP/ATS/SIS. 2001 SCCM/ESICM/ACCP/ATS/SIS International Sepsis Definitions Conference.Crit Care Med.2003; 31(4): 1250–1256.
28.
VincentJ.L., MorenoR., TakalaJ.The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine.Intensive Care Med.1996; 22(7): 707–710.
29.
Le GallJ.R., LemeshowS., SaulnierF.. Simplified Acute Physiologic Score. A new simplified acute physiologic score (SAPSII) based on European/North American multicenter study.JAMA.1993; 27(24): 2957–2963.
30.
Martín-MaloA., CarracedoJ., RamírezR.Effect of uremia and dialysis modality on mononuclear cell apoptosis.J Am Soc Nephrol.2000; 11(5): 936–942.
31.
PapathanassoglouE.D., MoynihanJ.A., AckermanM.H.. Does programmed cell death (apoptosis) play a role in the development of multiple organ dysfunction in critically ill patients? A review and a theoretical framework.Crit Care Med.2000; 28(2): 537–549.
32.
Haag-WeberM., HörlW.H.. Uremia and infection: mechanisms of impaired cellular host defense.Nephron.1993; 63(2): 125–131.
33.
SaudanP., NiederbergerM., De SeigneuxS.Adding a dialysis dose to continuous hemofiltration increases survival in patients with acute renal failure.Kidney Int.2006; 70(7): 1312–1317.
34.
TolwaniA.J., CampbellR.C., StofanB.S., LaiK.R., OsterR.A., WilleK.M.. Standard versus high-dose CVVHDF for ICU-related acute renal failure.J Am Soc Nephrol.2008; 19(6): 1233–1238.
