Intensity of Continuous Renal Replacement Therapy in Acute Kidney Injury in the Intensive Care Unit: A Systematic Review and Meta-Analysis

Abstract

Background and Objective: Acute kidney injury is a common finding among patients in the intensive care unit (ICU) and is an independent predictor of mortality. The optimal intensity and timing of continuous renal replacement therapy (CRRT), in critically ill patients remain unclear. The purpose of this study was to conduct a systematic review and meta-analysis of all prospective randomized controlled trials (RCTs) to determine the effect of intensity of CRRT on the survival of patients with acute renal failure (ARF) in ICU setting. Methods: Search strategy and data source. Electronic databases were searched on MEDLINE (through February 2010), ISIWeb of Science, and Cochrane Central Register of Controlled Trials (2010); Pub Med ‘‘Related articles.’’ Trial authors were also contacted for additional information. Study selection and data abstraction. All prospective clinical trials comparing the intensity of CRRT in adult patients with ARF and with explicit reporting of mortality were included. Three authors independently evaluated articles for eligibility and extracted data on study quality and outcomes. Meta-analysis used a random-effects model. Result: Of the 322 citations, 5 trials (n = 2402) were included in the meta-analysis, which met all the inclusion and exclusion criteria. Meta-analysis showed that in critically ill patients with acute kidney injury, the high-dose CRRT did not reduce mortality at 28 days. (risk ratio [RR], 0.88; 95% confidence interval [CI], 0.70-1.11; P = 0.28). Conclusion: In critically ill patients with acute kidney injury, the high-dose CRRT did not reduce mortality at 28 days.

Keywords

acute kidney injury intensive care unit continuous renal replacement therapy

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References

Hoste EA , Clermont G. , Kersten A. , et al. RIFLE criteria for acute kidney injury are associated with hospital mortality in critically ill patients: a cohort analysis. Crit Care. 2006;10(3):R73.

Uchino S. , Bellomo R. , Goldsmith D. , Bates S. , Ronco C. An assessment of the RIFLE criteria for acute renal failure in hospitalized patients. Crit Care Med. 2006;34(7):1913-1917.

Brivet FG , Kleinknecht DJ , Loirat P. , Landais PJ Acute Renal failure in intensive care units-causes, outcome, and prognostic factors of hospital mortality; a prospective, multicenter Study. French Study Group on Acute Renal failure. Crit Care Med. 1996;24(2):192-198.

Clermont G. , Acker CG , Angus DC , Sirio CA , Pinsky MR , Johnson JP Renal failure in the ICU: Comparison of the impact of acute renal failure and end-stage renal disease on ICU outcomes. Kidney Int. 2002;62(3):986-996.

Kellum JA , Angus DC Patients are dying of acute renal failure. Crit Care Med. 2002;30(9):2156-2157.

Liangos O. , Wald R. , O’Bell JW , Price L. , Pereira BJ , Jaber BL Epidemiology and outcomes of acute renal failure in hospitalized patients: a national survey. Clin J Am Soc Nephrol. 2006;1(1): 43-51.

Mehta RL , Pascual MT , Soroko S. , et al. Spectrum of acute renal failure in the intensive care unit: the PICARD experience. Kidney Int. 2004;66(4):1613-1621.

Thadhani R, Pascual M, Bonventre JV. Acute renal failure. N Engl J Med. 1996;334(22):1448-1460.

Uchino S. , Kellum JA , Bellomo R. , et al. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA. 2005;294(7):813-818.

10.

Ronco C. , Bellomo R. , Homel P. , et al. Effects of different doses in continuous veno-venous haemofiltration on outcomes of acute renal failure: a prospective randomized trial. Lancet. 2000; 355(9223):26-30.

11.

Saudan P. , Niederberger M. , De Siegneux S. , et al. Adding a dialysis dose to continuous hemofiltration increases survival in patients with acute renal failure. Kidney Int . 2006;70(7):1312-1317.

12.

Bouman CS , Oudemans-Van Straaten HM , Tijssen JG , Zandstra DF , Kesecioglu J. 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.

13.

Tolwani AJ , Campbell RC , Stofan BS , Lai KR , Oster RA , Wille KM Standard versus high-dose CVVHDF for ICUrelated acute renal failure . J Am Soc Nephrol. 2008;19(6): 1233-1238.

14.

VA/NIH Acute Renal Failure Trial Network. Palevsky PM , Zhang JH , O’Connor TZ , et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. 2008; 359(1):7-20.

15.

Bellomo R. , Cass A. , Cole L. , et al. and for the RENAL Replacement Therapy Study Investigators. Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med. 2009;361(17):1627-1638.

16.

Higgins JP , Thompson SG Quantifying heterogeneity in a meta-analysis. Stat Med. 2002;21(11):1539-1558.

17.

Higgins JPT , Thompson SG , Deeks JJ , et al. Measuring inconsistency in meta-analyses . BMJ . 2003;327(7414):557-560.

18.

Marshall MR , Golper TA , Shaver MJ , Alam MG , Chatoth DK Sustained low-efficiency dialysis for critically ill patients requiring renal replacement therapy. Kidney Int . 2001;60(2): 777-785. Erratum in: Kidney Int. 2001;60(4):1629.

19.

Uchino S. , Bellomo R. , Morimatsu H. , et al. Continuous renal replacement therapy: a worldwide practice survey. The beginning and ending supportive therapy for the kidney (B.E.S.T. kidney) investigators. Intensive Care Med. 2007;33(9):1563-1570. Epub 2007;27.

20.

Bellomo R. , Farmer M. , Boyce N. A prospective study of continuous venovenous hemodiafiltration in critically ill patients with acute renal failure. J Intensive Care Med . 1995;10(4):187-192.

21.

Palevsky PM , Zhang JH , O’Connor TZ , et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. 2008;359(1):7-20.

22.

Vesconi S. , Cruz DN , Fumagalli R. , et al. Delivered dose of renal replacement therapy and mortality in critically ill patients with acute kidney injury. Crit Care. 2009;13(2):R57. Epub 2009.

23.

Monti G. , Herrera M. , Kindgen-Milles D. , et al. The DOse REsponse Multicentre International Collaborative Initiative (DO-RE-MI). Contrib Nephrol. 2007;156:434-443.

24.

Cappelleri JC , Ioannidis JP , Schmid CH , et al. Large trials vs meta-analysis of smaller trials: how do their results compare? [see comments] . JAMA . 1996;276(16):1332-1338.

25.

Ioannidis JP , Cappelleri JC , Lau J. Issues in comparisons between eta-analyses and large trials. J Am Med Assoc. 1998;279(14): 1089-1109.

26.

Bagshaw SM , Berthiaume LR , Delaney A. , Bellomo R. Continuous versus intermittent renal replacement therapy for critically ill patients with acute kidney injury: a meta-analysis. Crit Care Med. 2008;36(2):610-617.

27.

Pannu N. , Klarenbach S. , Wiebe N. , et al. Renal replacement therapy in patients with acute renal failure: a systematic review. JAMA. 2008;299(7):793-805.

28.

Van Wert R. , Friedrich JO , Scales DC , Wald R. , Adhikari NK ;. University of Toronto Acute Kidney Injury Research Group. High-dose renal replacement therapy for acute kidney injury: systematic review and meta-analysis. Crit Care Med. 2010;38(5): 1360-1369.

29.

RENAL Study Investigators. Renal replacement therapy for acute kidney injury in Australian and New Zealand intensive care units: a practice survey. Crit Care Resusc . 2008;10(3):225-230.

30.

Overberger P. , Pesacreta M. , Palevsky PM , et al. Management of renal replacement therapy in acute kidney injury: a survey of practitioner prescribing practices. Clin J Am Soc Nephrol. 2007; 2(4):623-630.

31.