Continuous renal replacement therapy versus intermittent hemodialysis in intensive care patients: impact on mortality and renal recovery
- 5k Downloads
The best renal replacement therapy (RRT) modality remains controversial. We compared mortality and short- and long-term renal recovery between patients treated with continuous RRT and intermittent hemodialysis.
Patients of the prospective observational multicenter cohort database OUTCOMEREA™ were included if they underwent at least one RRT session between 2004 and 2014. Differences in patients’ baseline and daily characteristics between treatment groups were taken into account by using a marginal structural Cox model, allowing one to substantially reduce the bias resulting from confounding factors in observational longitudinal data analysis. The composite primary endpoint was 30-day mortality and dialysis dependency.
Among 1360 included patients with RRT, 544 (40.0 %) and 816 (60.0 %) were initially treated by continuous RRT and intermittent hemodialysis, respectively. At day 30, 39.6 % patients were dead. Among survivors, 23.8 % still required RRT. There was no difference between groups for the primary endpoint in global population (HR 1.00, 95 % CI 0.77–1.29; p = 0.97). In patients with higher weight gain at RRT initiation, mortality and dialysis dependency were significantly lower with continuous RRT (HR 0.54, 95 % CI 0.29–0.99; p = 0.05). Conversely, this technique appeared to be deleterious in patients without shock (HR 2.24, 95 % CI 1.24–4.04; p = 0.01). Six-month mortality and persistent renal dysfunction were not influenced by the RRT modality in patients with dialysis dependence at ICU discharge.
Continuous RRT did not appear to improve 30-day and 6-month patient outcomes. It seems beneficial for patients with fluid overload, but might be deleterious in the absence of hemodynamic failure.
KeywordsRenal replacement therapy Acute kidney injury Intensive care unit Marginal structural model
The authors thank Celine Feger, M.D. (EMIBiotech), for her editorial support.
Members of the Outcomerea Study Group
Scientific Committee: Jean-François Timsit (Medical and Infectious Diseases ICU, Bichat-Claude Bernard Hospital, Paris, France; UMR 1137 Inserm–Paris Diderot University IAME, F75018, Paris); Elie Azoulay (Medical ICU, Saint Louis Hospital, Paris, France); Maïté Garrouste-Orgeas (ICU, Saint-Joseph Hospital, Paris, France); Jean-Ralph Zahar (Infection Control Unit, Angers Hospital, Angers, France); Christophe Adrie (ICU, Delafontaine Hospital, Saint Denis, and Physiology, Cochin Hospital, Paris, France); Michael Darmon (Medical ICU, Saint Etienne University Hospital, St Etienne, France); and Christophe Clec’h (ICU, Avicenne Hospital, Bobigny, and UMR 1137 Inserm–Paris Diderot university IAME, F75018, Paris, France).
Biostatistical and Information System Expertise: Jean-Francois Timsit (Medical and Infectious Diseases ICU, Bichat-Claude Bernard Hospital, Paris, France; UMR 1137 Inserm–Paris Diderot university IAME, F75018, Paris); Corinne Alberti (Medical Computer Sciences and Biostatistics Department, Robert Debré Hospital, Paris, France); Adrien Français (Integrated Research Center U823, Grenoble, France); Aurélien Vesin (OUTCOMEREA organization and Integrated Research Center U823, Grenoble, France); Stephane Ruckly (OUTCOMEREA organization and Inserm UMR 1137 IAME, F75018, Paris); Sébastien Bailly (Grenoble University Hospital Inserm UMR 1137 IAME, F75018, Paris) and Christophe Clec’h (ICU, Avicenne Hospital, Bobigny, and Inserm UMR 1137 IAME, F75018, Paris, France); Frederik Lecorre (Supelec, France); Didier Nakache (Conservatoire National des Arts et Métiers, Paris, France); and Aurélien Vannieuwenhuyze (Tourcoing, France).
Investigators of the OUTCOMEREA Database: Christophe Adrie (ICU, Delafontaine Hospital, Saint Denis, and Physiology, Cochin Hospital, Paris, France); Bernard Allaouchiche (ICU, Pierre Benite Hospital, Lyon, France); Laurent Argaud (Medical ICU, Hospices Civils de Lyon, Lyon, France); Claire Ara-Somohano (Medical ICU, University Hospital, Grenoble, France); Elie Azoulay (Medical ICU, Saint Louis Hospital, Paris, France); Francois Barbier (medical-surgical ICU, Orleans, France), Jean-Pierre Bedos (ICU, Versailles Hospital, Versailles, France); Julien Bohé (ICU, Hôpital Pierre Benite, Lyon France), Lila Bouadma (ICU, Bichat Hospital, Paris, France); Christine Cheval (ICU, Hyeres Hospital, Hyeres, France); Christophe Clec’h (ICU, Avicenne Hospital, Bobigny, France); Michael Darmon (ICU, Saint Etienne Hospital, Saint Etienne, France); Anne-Sylvie Dumenil (Antoine Béclère Hospital, Clamart, France); Claire Dupuis (Bichat hospital and UMR 1137 Inserm–Paris Diderot University IAME, F75018, Paris, France), Marc Gainier hôpital la Timone, Marseille, France), Akim Haouache (Surgical ICU, H Mondor Hospital, Creteil, France); Samir Jamali (ICU, Dourdan, Dourdan Hospital, Dourdan, France); Hatem Khallel (ICU, Cayenne General Hospital, Cayenne, France); Alexandre Lautrette (ICU, G Montpied Hospital, Clermont-Ferrand, France); Guillaume Marcotte (Surgical ICU, Hospices Civils de Lyon, Lyon, France); Eric Le Miere (ICU, Louis Mourier Hospital, Colombes, France); Maxime Lugosi (Medical ICU, University Hospital Grenoble, Grenoble, France); Bruno Mourvillier (ICU, Bichat Hospital, Paris, France); Benoît Misset (ICU, Saint-Joseph Hospital, Paris, France); Delphine Moreau (ICU, Saint-Louis Hospital, Paris, France); Bruno Mourvillier (ICU, Bichat Hospital, Paris, France); Laurent Papazian (Hopital Nord, Marseille, France), Benjamin Planquette (pulmonology ICU, George Pompidou Hospital, Versailles, France); Bertrand Souweine (ICU, G Montpied Hospital, Clermont-Ferrand, France); Carole Schwebel (ICU, A Michallon Hospital, Grenoble, France); Gilles Troché (ICU, Antoine Béclère Hospital, Clamart, France); Marie Thuong (ICU, Delafontaine Hospital, Saint Denis, France); Guillaume Thierry (ICU, Saint-Louis Hospital, Paris, France); Dany Toledano (ICU, Gonesse Hospital, Gonesse, France); and Eric Vantalon (SICU, Saint-Joseph Hospital, Paris, France).
Study Monitors: Julien Fournier, Caroline Tournegros, Stéphanie Bagur, Mireille Adda, Vanessa Vindrieux, Loic Ferrand, Nadira Kaddour, Boris Berthe, Samir Bekkhouche, Kaouttar Mellouk, Sylvie Conrozier, Igor Theodose, Veronique Deiler, and Sophie Letrou.
Compliance with ethical standards
The study was entirely funded by the OUTCOMEREA research network. AST received an educational grant from the French Kidney Foundation under the aegis of the French Medical Research Foundation; code DEA2014FDR/FRM04_FdR-SdN-SFD_FRM_TRUCHE.
Conflicts of interest
The authors declare that they have no conflict of interest.
- 1.Clec’h C, Gonzalez F, Lautrette A, Nguile-Makao M, Garrouste-Orgeas M, Jamali S, Golgran-Toledano D, Descorps-Declere A, Chemouni F, Hamidfar-Roy R, Azoulay E, Timsit JF (2011) Multiple-center evaluation of mortality associated with acute kidney injury in critically ill patients: a competing risks analysis. Crit Care 15:R128CrossRefPubMedPubMedCentralGoogle Scholar
- 5.Rabindranath K, Adams J, Macleod AM, Muirhead N (2007) Intermittent versus continuous renal replacement therapy for acute renal failure in adults. Cochrane Database Syst Rev: CD003773Google Scholar
- 6.Vinsonneau C, Camus C, Combes A, Costa de Beauregard MA, Klouche K, Boulain T, Pallot JL, Chiche JD, Taupin P, Landais P, Dhainaut JF (2006) Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. Lancet 368:379–385CrossRefPubMedGoogle Scholar
- 7.Lins RL, Elseviers MM, Van der Niepen P, Hoste E, Malbrain ML, Damas P, Devriendt J (2009) Intermittent versus continuous renal replacement therapy for acute kidney injury patients admitted to the intensive care unit: results of a randomized clinical trial. Nephrol Dial Transplant 24:512–518CrossRefPubMedGoogle Scholar
- 12.Wald R, Shariff SZ, Adhikari NK, Bagshaw SM, Burns KE, Friedrich JO, Garg AX, Harel Z, Kitchlu A, Ray JG (2014) The association between renal replacement therapy modality and long-term outcomes among critically ill adults with acute kidney injury: a retrospective cohort study. Crit Care Med 42:868–877CrossRefPubMedGoogle Scholar
- 13.KDIGO (2011) Section 5: dialysis interventions for treatment of AKI. Kidney Int Suppl 2:89–115Google Scholar
- 16.Clec’h C, Alberti C, Vincent F, Garrouste-Orgeas M, de Lassence A, Toledano D, Azoulay E, Adrie C, Jamali S, Zaccaria I, Cohen Y, Timsit JF (2007) Tracheostomy does not improve the outcome of patients requiring prolonged mechanical ventilation: a propensity analysis. Crit Care Med 35:132–138CrossRefPubMedGoogle Scholar
- 18.John S, Griesbach D, Baumgartel M, Weihprecht H, Schmieder RE, Geiger H (2001) Effects of continuous haemofiltration vs intermittent haemodialysis on systemic haemodynamics and splanchnic regional perfusion in septic shock patients: a prospective, randomized clinical trial. Nephrol Dial Transplant 16:320–327CrossRefPubMedGoogle Scholar
- 20.Palevsky PM, Zhang JH, O’Connor TZ, Chertow GM, Crowley ST, Choudhury D, Finkel K, Kellum JA, Paganini E, Schein RM, Smith MW, Swanson KM, Thompson BT, Vijayan A, Watnick S, Star RA, Peduzzi P (2008) Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med 359:7–20CrossRefPubMedGoogle Scholar
- 21.Bailly S, Pirracchio R, Timsit JF (2016) What’s new in the quantification of causal effects from longitudinal cohort studies: a brief introduction to marginal structural models for intensivists. Intensive Care Med 42:576–579Google Scholar
- 28.Teixeira C, Garzotto F, Piccinni P, Brienza N, Iannuzzi M, Gramaticopolo S, Forfori F, Pelaia P, Rocco M, Ronco C, Anello CB, Bove T, Carlini M, Michetti V, Cruz DN (2013) Fluid balance and urine volume are independent predictors of mortality in acute kidney injury. Crit Care 17:R14CrossRefPubMedPubMedCentralGoogle Scholar
- 34.Jun M, Heerspink HJ, Ninomiya T, Gallagher M, Bellomo R, Myburgh J, Finfer S, Palevsky PM, Kellum JA, Perkovic V, Cass A (2010) Intensities of renal replacement therapy in acute kidney injury: a systematic review and meta-analysis. Clin J Am Soc Nephrol 5:956–963CrossRefPubMedPubMedCentralGoogle Scholar