Association between renal replacement therapy in critically ill patients with severe acute kidney injury and mortality

doi:10.1016/j.jcrc.2013.08.002

Journal of Critical Care

Volume 28, Issue 6, December 2013, Pages 1011-1018

https://doi.org/10.1016/j.jcrc.2013.08.002 Get rights and content

Abstract

Purpose

To evaluate the characteristics and outcomes of critically ill patients with severe acute kidney injury (AKI) treated and not treated with renal replacement therapy (RRT).

Methods

Secondary analysis of a multi-centre cohort study. Primary exposure was RRT. Primary outcome was propensity and multi-variable adjusted-hospital mortality.

Results

We studied 1250 patients (71.3%) who received and 502 (28.7%) who did not receive RRT. Reasons for not starting RRT (not mutually exclusive) were limitations of support (33.6%, n = 169), adequate urine output (46.2%; n = 232), plan to observe (56.4%; n = 283), and advanced age (12.6%; n = 63). Mortality was higher in those not receiving RRT due to limitations and advanced age but lower for adequate urine output and plan to observe. Propensity and multi-variable adjusted analysis showed no statistical difference in hospital mortality (adj-OR 1.47; 95% CI, 0.93-2.24) in patients receiving RRT. Results were similar in a sensitivity analysis restricted to patients fulfilling risk, injury, failure, loss, end-stage kidney disease-FAILURE criteria (37.0%; n = 446) (adj-OR 1.36; 95% CI, 0.70-2.66).

Conclusion

In this cohort, reasons for not starting RRT included limitations of support and perception of impending renal recovery. Despite similar risk of mortality after adjusting for selection bias and confounders, RRT-treated patients were fundamentally different from non-treated patients across a spectrum of variables that precludes valid comparison in observational data.

Introduction

Acute kidney injury (AKI) is a well recognized complication of critical illness with an important impact on outcome and health resource utilization [1]. In critically ill patients, the development of more advanced forms of AKI can contribute to severe disruption in metabolic, azotemic, and fluid balance homeostasis. In these circumstances, a trial of support with renal replacement therapy (RRT) may be indicated [1], [2], [3].

Nevertheless, there is uncertainty in clinical practice of the ideal circumstances for “when” and in “whom” RRT should be started especially in the absence of clear life-threatening complications [4], [5]. Recent data, largely from observational studies, have implied that the timing of support with RRT may be a modifiable factor impacting outcome in severe AKI [6], [7]. However, the application of RRT is complex and may be associated with risk for adverse events and less favorable outcome [8], [9]. Additionally, provision of RRT clearly represents a measurable intensification in support and costs of care [10].

In studies evaluating the optimal timing for RRT, no threshold, trigger or factor has consistently been associated with improved outcomes nor has confidently emerged as a guide to clinical practice [11], [12]. Few studies to date have evaluated the rationale and reasons for not initiating RRT in critically ill patients with severe AKI or described the implications of no RRT on clinical outcomes [8], [9].

We hypothesized that, in critically ill patients with severe AKI, RRT initiation would reduce mortality when compared to patients who appeared similarly eligible but not receiving RRT. Our objectives were to describe among critically ill patients with severe AKI (1) the reported rationale for not initiating RRT; (2) the characteristics, physiology, and treatment intensity among those receiving or not receiving RRT; and (3) the mortality among those receiving and not receiving RRT.

Section snippets

Methods [13]

The Health Research Ethics Board at each participating center approved the study protocol. The requirement for written consent was waived.

Results

In total, there were 1,753 critically ill patients with severe AKI, of which, 1,250 (71.3%) received RRT and 503 (28.7%) did not receive RRT (Fig. 1).

Discussion

We performed a secondary analysis from a large prospective international observational study to describe the characteristics, course and outcomes of a cohort of critically ill patients with severe AKI who received or did not receive support with RRT.

Acknowledgments

Dr. Bagshaw is supported by a Canada Research Chair in Critical Care Nephrology and Clinical Investigator Award from Alberta Innovates—Health Solutions. This study was funded in part by an unrestricted educational grant from the Austin Hospital Intensive Care Trust Fund.

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^☆: Disclosures: All authors have seen and approved the final version of the manuscript. Drs Bagshaw, Kellum, Gibney, Oudemans-van Straaten, and Bellomo have consulted for Gambro. Dr Kellum has consulted for Baxter, Inc. Dr Oudemans-van Straaten has consulted for Fresenius Medical Care.

^☆☆: Funding Sources: This study was funded in part by an unrestricted educational grant from the Austin Hospital Intensive Care Trust Fund.

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Clinical PotpourriAssociation between renal replacement therapy in critically ill patients with severe acute kidney injury and mortality☆,☆☆

Abstract

Purpose

Methods

Results

Conclusion

Introduction

Section snippets

Methods [13]

Results

Discussion

Acknowledgments

Acute renal failure in critically ill patients: a multinational, multicenter study

JAMA

Prognosis for long-term survival and renal recovery in critically ill patients with severe acute renal failure: a population-based study

Crit Care

Population-based incidence, mortality and quality of life in critically ill patients treated with renal replacement therapy - A nationwide retrospective cohort study in Finnish ICUs

Crit Care

Timing of initiation of renal replacement therapy for acute kidney injury: a survey of nephrologists and intensivists in Canada

Nephrol Dial Transplant

Timing of dialysis initiation in AKI in ICU: international survey

Crit Care

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

Timing of renal replacement therapy initiation in acute renal failure: a meta-analysis

Am J Kidney Dis

Efficacy of renal replacement therapy in critically ill patients: a propensity analysis

Crit Care

Renal replacement therapy is an independent risk factor for mortality in critically ill patients with acute kidney injury

Crit Care

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

Crit Care Med

Timing of renal replacement therapy and clinical outcomes in critically Ill patients with severe acute kidney failure

J Crit Care

Clinical factors associated with initiation of renal replacement therapy in critically ill patients with acute kidney injury — a prospective multicenter observational study

J Crit Care

Strengthening the Reporting of Observational Studies in Epidemiology (STROBE) statement: guidelines for reporting observational studies

BMJ

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

A new Simplified Acute Physiology Score (SAPS-II) based on a European/North American multicenter study

JAMA

The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure

Intensive Care Med

Clinical Potpourri
Association between renal replacement therapy in critically ill patients with severe acute kidney injury and mortality☆,☆☆