Impact of the intensity of intermittent renal replacement therapy in critically ill patients

Abstract

Background

Intermittent renal replacement therapy (IRRT) is prescribed across intensive care units (ICU) worldwide. While research regarding the prescribed dialysis dose has not yielded results concerning mortality, it is still unknown whether the same applies to the actual delivered dose.

Methods

We retrospectively analyzed two different cohorts of patients (562 IRRT sessions) who were admitted to the intensive care units at Hospital Clínic of Barcelona and required renal replacement therapy with IRRT. The first cohort included patients with acute kidney injury (AKI) (n = 42) and the second included patients already on chronic hemodialysis (CKD 5D) (n = 47). Only patients who had at least 3 recorded hemodialysis sessions in the ICU and with no previous continuous renal replacement therapy (CRRT) were included. The achieved dose was measured as Kt (L) by ionic dialysance and the primary endpoint was 90-day mortality.

Results

Ninety-day mortality was 40.5% (n = 17) in the AKI cohort and 23.9% (n = 11) in the CKD 5D cohort with mean Kt of 43 ± 8.27 L and 47 ± 9.65 L respectively. Kt dose of IRRT was associated with 90-day mortality in the AKI cohort in a multivariate surveillance analysis adjusted for confounding factors (HR 0.935 [0.88–0.99], p = 0.02). Only the Kt dose and age remained statistically associated with the outcome in the AKI cohort.

Conclusions

Delivered dialysis dose as measured by ionic-dialysance Kt may be associated with survival in critically-ill patients with AKI, while it does not seem to affect outcomes in critically-ill CKD 5D patients. This exploratory analysis will need confirmation in larger prospective studies.

This is a preview of subscription content, access via your institution.

Fig. 1
Fig. 2

Data availability

The datasets used and/or analysed during the current study are available from the corresponding author on reasonable request.

References

  1. 1.

    Rizo-Topete LM, Arellano-Torres M, Hernández-Portales J, Treviño-frutos R, Monreal-puente R (2015) Renal replacement therapies in acute kidney injury in Intensive Care Unit, continuous renal replacement, hybrid, and conventional hemodialysis: survival analysis. Dial Traspl 36:8–14

    Google Scholar 

  2. 2.

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

    Article  Google Scholar 

  3. 3.

    Ostermann M, Chang RW (2007) Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med 35(8):1837–1843

    Article  Google Scholar 

  4. 4.

    Szamosfalvi B, Yee J (2013) Considerations in the critically ill ESRD patient. Adv Chronic Kidney Dis 20(1):102–109

    Article  Google Scholar 

  5. 5.

    Uehlinger DE, Jakob SM, Ferrari P et al (2005) Comparison of continuous and intermittent renal replacement therapy for acute renal failure. Nephrol Dial Transpl 2(8):1630–1637

    Article  Google Scholar 

  6. 6.

    Schefold JC, von Haehling S, Pschowski R et al (2014) The effect of continuous versus intermittent renal replacement therapy on the outcome of critically ill patients with acute renal failure (CONVINT): a prospective randomized controlled trial. Crit Care 18(1):R11

    Article  Google Scholar 

  7. 7.

    Lins RL, Elseviers MM, Van der Niepen P et al (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 Transpl 24(2):512–518

    Article  Google Scholar 

  8. 8.

    Jun M, Heerspink HJ, Ninomiya T et al (2010) Intensities of renal replacement therapy in acute kidney injury: a systematic review and meta-analysis. Clin J Am Soc Nephrol 5(6):956–963

    Article  Google Scholar 

  9. 9.

    Nash DM, Przech S, Wald R, O’Reilly D (2017) Systematic review and meta-analysis of renal replacement therapy modalities for acute kidney injury in the intensive care unit. J Crit Care 41:138–144

    Article  Google Scholar 

  10. 10.

    Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group (2012) Clinical practice guidelines for acute kidney injury. Kidney Int 2:1–138

    Article  Google Scholar 

  11. 11.

    Schwenger V, Weigand MA, Hoffmann O et al (2012) Sustained low efficiency dialysis using a single-pass batch system in acute kidney injury—a randomized interventional trial: the renal replacement therapy study in intensive care unit patients. Crit Care 16(5):451

    Article  Google Scholar 

  12. 12.

    Lyndon WD, Wille KM, Tolwani AJ (2012) Solute clearance in CRRT: prescribed dose versus actual delivered dose. Nephrol Dial Transpl 27(3):952–956

    CAS  Article  Google Scholar 

  13. 13.

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

    Article  Google Scholar 

  14. 14.

    Macedo E, Claure-Del Granado R, Mehta RL (2011) Effluent volume and dialysis dose in CRRT: time for reappraisal. Nat Rev Nephrol 8(1):57–60

    Article  Google Scholar 

  15. 15.

    Van Wert R, Friedrich JO, Scales DC, Wald R, Adhikari NK (2010) High-dose renal replacement therapy for acute kidney injury: systematic review and meta-analysis. Crit Care Med 38(5):1360–1369

    Article  Google Scholar 

  16. 16.

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

    Article  Google Scholar 

  17. 17.

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

    CAS  Article  Google Scholar 

  18. 18.

    Schiffl H, Lang SM, Fischer R (2002) Daily hemodialysis and the outcome of acute renal failure. N Engl J Med 346(5):305–310

    Article  Google Scholar 

  19. 19.

    Eknoyan G, Beck GJ, Cheung AK, Daugirdas JT, Greene T, Kusek JW et al (2002) Effect of dialysis dose and membrane flux in maintenance hemodialysis. N Engl J Med. 347:2010–2019

    Article  Google Scholar 

  20. 20.

    Maduell F, Ramos R, Varas J et al (2016) Hemodialysis patients receiving a greater Kt dose than recommended have reduced mortality and hospitalization risk. Kidney Int 90(6):1332–1341

    Article  Google Scholar 

  21. 21.

    Gotch FA, Sargent JA, Keen ML (2000) Whither goest Kt/V? Kidney Int Suppl 76:S3–S18

    CAS  Article  Google Scholar 

  22. 22.

    Clark WR, Mueller BA, Kraus MA et al (1998) Renal replacement therapy quantification in acute renal failure. Nephrol Dial Transpl 13(Suppl 6):86–90

    Article  Google Scholar 

  23. 23.

    Schiffl H, Fischer R, Lang SM (2014) Assessment of dialysis dose in critically ill maintenance dialysis patients. Ther Apher Dial 18(5):468–472

    Article  Google Scholar 

  24. 24.

    Lindsay RM, Bene B, Goux N, Heidenheim AP, Landgren C, Sternby J (2001) Relationship between effective ionic dialysance and in vivo urea clearance during hemodialysis. Am J Kidney Dis 38(3):565–574

    CAS  Article  Google Scholar 

  25. 25.

    Ridel C, Osman D, Mercadal L et al (2007) Ionic dialysance: a new valid parameter for quantification of dialysis efficiency in acute renal failure? Intensive Care Med 33(3):460–465

    CAS  Article  Google Scholar 

  26. 26.

    Maduell F, Ramos R, Palomares I et al (2013) Impact of targeting Kt instead of Kt/V. Nephrol Dial Transpl 28(10):2595–2603

    Article  Google Scholar 

  27. 27.

    Lowrie EG, Chertow GM, Lew NL, Lazarus JM, Owen WF (1999) The urea [clearance x dialysis time] product (Kt) as an outcome-based measure of hemodialysis dose. Kidney Int 56(2):729–737

    CAS  Article  Google Scholar 

  28. 28.

    Ahmad S, Misra M, Hoenich N, Daugirdas JT (2007) Hemodialysis apparatus. In: Daugirdas JT, Blake PG, Ing TS (eds) Handbook of dialysis, 4th edn. Williams & Wilkins, Philadelphia, USA

    Google Scholar 

  29. 29.

    Faulhaber-Walter R, Hafer C, Jahr N et al (2009) The hannover dialysis outcome study: comparison of standard versus intensified extended dialysis for treatment of patients with acute kidney injury in the intensive care unit. Nephrol Dial Transpl 24:2179

    Article  Google Scholar 

  30. 30.

    Rabb H, Griffin MD, McKay DB et al (2016) Inflammation in AKI: current understanding, key questions, and knowledge gaps. J Am Soc Nephrol 27(2):371–379

    CAS  Article  Google Scholar 

  31. 31.

    Park JT, Kee YK, Oh HJ et al (2016) High-dose versus conventional-dose continuous venovenous hemodiafiltration and patient and kidney survival and cytokine removal in sepsis-associated acute kidney injury: a randomized controlled trial. Am J Kidney Dis 68(4):599–608

    Article  Google Scholar 

  32. 32.

    Joannes-Boyau O, Honoré PM, Perez P et al (2013) High-volume versus standard-volume haemofiltration for septic shock patients with acute kidney injury (IVOIRE study): a multicentre randomized controlled trial. Intensive Care Med 39:1535–1546

    Article  Google Scholar 

  33. 33.

    Serra Cabañas N, Barros Freiria X, Martinez Garro M, Blasco Pelícano M, Maduell Canals F, Torras Rabasa A et al (2010) La medida de la dosis de diálisis mediante Kt por dialisancia iónica revela una menor adecuación que la medida por Kt/Vurea en la insuficiencia renal aguda de pacientes críticos. Nefrología 30(2):232–235

    PubMed  Google Scholar 

  34. 34.

    Simmons J, Pittet J-F (2015) The coagulopathy of sepsis. Curr Opin Anaesthesiol 28(2):227–236

    CAS  Article  Google Scholar 

  35. 35.

    Murray PT, Brady HR, Hall JB (2006) Intensive care in nephrology. Taylor and Francis, Abingdon

    Google Scholar 

Download references

Acknowledgements

Hospital Clínic Intensive Care Working Group (GTMC, Grup de treball del Malalt crític): Sara Fernández, Josep Maria Nicolàs, Pedro Castro, Intensive Care Unit, Internal Medicine Department, Hospital Clínic, IDIBAPS; Rut Andrea, Xavier Bosch, José Tomás Ortiz, Acute Cardiac Care, Cardiology Department, Hospital Clínic, IDIBAPS; Enric Reverter, Javier Fernández, Àngels Escorsell, Intensive Care Unit, Hepatology Department, Hospital Clínic, IDIBAPS; Jordi Mercadal, Carlos Ferrando, Xavier Borrat, Surgical ICU, Anesthesiology Department, Hospital Clínic, IDIBAPS; Antoni Torres, Joan Ramón Badia, Miquel Ferrer, Intensive Care Unit, Pneumology Department, Hospital Clínic, IDIBAPS; Eduard Quintana, Daniel Pereda, Elena Sandoval, Manel Castellà, Irene Rovira, Intensive care unit, Cardiovascular-Surgery Department, Hospital Clínic, IDIBAPS.

Funding

The authors received no financial support for the research, authorship, and publication of this article.

Author information

Affiliations

Authors

Consortia

Contributions

AMA, PS and EP contributed to the study conception and design. Material preparation, data collection and analysis were performed byAMA, PA and ER. The first draft of the manuscript was written by Alícia Molina. MB, DC, GP, RA, SF, ER, JM and EQ: have interpreted the data, revised the manuscript, provided intellectual content and approved the final version.

Corresponding author

Correspondence to Esteban Poch.

Ethics declarations

Conflict of interest

No potential conflict of interest was reported by the authors. The results presented in this paper have not been published previously in whole or part, except in abstract format.

Ethical approval

The Study was approved by the Ethics Committee of the Hospital Clinic and conformed to the ethical guidelines of the Helsinki Declaration (as revised in Tokyo 2004).

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOCX 15 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Molina-Andújar, A., Alcubilla, P., Santiago, P. et al. Impact of the intensity of intermittent renal replacement therapy in critically ill patients. J Nephrol 34, 105–112 (2021). https://doi.org/10.1007/s40620-020-00760-x

Download citation

Keywords

  • Intermittent renal replacement therapy
  • Dialysis dose
  • Acute kidney injury
  • Intensive care unit
  • Ionic dialysance
  • Kt