Renal outcomes according to renal replacement therapy modality and treatment protocol in the ATN and RENAL trials
Thummaporn Naorungroj, Ary Serpa Neto, Amanda Wang, Martin Gallagher, Rinaldo Bellomo, Thummaporn Naorungroj, Ary Serpa Neto, Amanda Wang, Martin Gallagher, Rinaldo Bellomo
Abstract
Background: In critically ill patients with acute kidney injury, renal replacement therapy (RRT) modality and treatment protocols may affect kidney recovery. This study explored whether RRT modality and treatment protocol affected RRT dependence in the 'Randomized Evaluation of Normal versus Augmented Level of RRT' and the 'Acute Renal Failure Trial Network' (ATN) trials.
Methods: Primary outcome was 28-day RRT dependence. Secondary outcomes included RRT dependence among survivors and in different SOFA-based treatment protocol groups. We used the Fine-Gray competing-risk model sub-distribution hazard ratio (SHR) to assess the primary outcome. Analyses were adjusted for confounders.
Results: Of 2542 patients, 2175 (85.5%) received continuous RRT (CRRT) and 367 (14.4%) received intermittent hemodialysis (IHD) as first RRT modality. CRRT-first patients had greater illness severity. After adjustment, there was no between-group difference in 28-day RRT dependence (SHR, 0.96 [95% CI 0.84-1.10]; p = 0.570) or hospital mortality (odds ratio [OR], 1.14 [95% CI 0.86-1.52]; p = 0.361) However, among survivors, CRRT-first was associated with decreased 28-day RRT dependence (OR, 0.54 [95% CI 0.37-0.80]; p = 0.002) and more RRT-free days (common OR: 1.38 [95% CI 1.11-1.71]). Moreover, among CRRT-first patient, the ATN treatment protocol was associated with fewer RRT-free days, greater mortality, and a fourfold increase in RRT dependence at day 28.
Conclusions: There was no difference in RRT dependence at day 28 between IHD and CRRT. However, among survivors and after adjustment, both IHD-first and the ATN treatment protocol were strongly associated with greater risk of RRT dependence at 28 days after randomization. Trial registration NCT00221013 registered September 22, 2005, and NCT00076219 registered January 19, 2004.
Keywords: Acute kidney injury; Continuous renal replacement therapy; Dialysis dependence; Intermittent hemodialysis; Mortality.
Conflict of interest statement
Dr Serpa Neto reported receiving grants and personal fees from Dräger, outside the submitted work. Dr Bellomo reported receiving grants from Baxter International outside the submitted work. Dr Naorungroj declared that they have no relevant financial interests. Dr Amanda Y Wang is supported by RACP Jacquot Research Establishment Fellowship, Australia.
© 2022. The Author(s).
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References
- Hoste EA, Bagshaw SM, Bellomo R, Cely CM, Colman R, Cruz DN, et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Med. 2015;41(8):1411–1423. doi: 10.1007/s00134-015-3934-7.
- Johansen KL, Smith MW, Unruh ML, Siroka AM, O'Connor TZ, Palevsky PM. Predictors of health utility among 60-day survivors of acute kidney injury in the Veterans Affairs/National Institutes of Health Acute Renal Failure Trial Network Study. Clin J Am Soc Nephrol. 2010;5(8):1366–1372. doi: 10.2215/CJN.02570310.
- Ethgen O, Schneider AG, Bagshaw SM, Bellomo R, Kellum JA. Economics of dialysis dependence following renal replacement therapy for critically ill acute kidney injury patients. Nephrol Dial Transpl. 2015;30(1):54–61. doi: 10.1093/ndt/gfu314.
- Kidney Disease Improving Global Outcomes (KDIGO) AKI Working Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl. 2012;2:1–138.
- Lins RL, Elseviers MM, Van der Niepen P, Hoste E, Malbrain ML, Damas P, et al. 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. 2009;24(2):512–518. doi: 10.1093/ndt/gfn560.
- Vinsonneau C, Camus C, Combes A, de Consta Beauregard MA, Klouche K, Boulain T, et al. Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. Lancet. 2006;368(9533):379–385. doi: 10.1016/S0140-6736(06)69111-3.
- Schneider AG, Bellomo R, Bagshaw SM, Glassford NJ, Lo S, Jun M, et al. Choice of renal replacement therapy modality and dialysis dependence after acute kidney injury: a systematic review and meta-analysis. Intensive Care Med. 2013;39(6):987–997. doi: 10.1007/s00134-013-2864-5.
- Bellomo R, Cass A, Cole L, Finfer S, Gallagher M, Lo S, et al. Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med. 2009;361(17):1627–1638. doi: 10.1056/NEJMoa0902413.
- Palevsky PM, Zhang JH, O'Connor TZ, Chertow GM, Crowley ST, Choudhury D, et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. 2008;359(1):7–20. doi: 10.1056/NEJMoa0802639.
- Schneider AG, Lipcsey M, Bailey M, Pilcher DV, Bellomo R. Simple translational equations to compare illness severity scores in intensive care trials. J Crit Care. 2013;28(5):885.e1–8. doi: 10.1016/j.jcrc.2013.02.003.
- Imai K, Ratkovic M. Covariate balancing propensity score. J Roy Stat Soc B. 2014;76(1):243–263. doi: 10.1111/rssb.12027.
- Kurth T, Walker AM, Glynn RJ, Chan KA, Gaziano JM, Berger K, et al. Results of multivariable logistic regression, propensity matching, propensity adjustment, and propensity-based weighting under conditions of nonuniform effect. Am J Epidemiol. 2006;163(3):262–270. doi: 10.1093/aje/kwj047.
- Tiao JY, Semmens JB, Masarei JR, Lawrence-Brown MM. The effect of age on serum creatinine levels in an aging population: relevance to vascular surgery. Cardiovasc Surg. 2002;10(5):445–451. doi: 10.1016/S0967-2109(02)00056-X.
- Bagshaw SM, Wald R, Adhikari NKJ, Bellomo R, da Costa BR, Dreyfuss D, et al. Timing of Initiation of renal-replacement therapy in acute kidney injury. N Engl J Med. 2020;383(3):240–251. doi: 10.1056/NEJMoa2000741.
- Gaudry S, Hajage D, Schortgen F, Martin-Lefevre L, Pons B, Boulet E, et al. Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med. 2016;375(2):122–133. doi: 10.1056/NEJMoa1603017.
- Barbar SD, Clere-Jehl R, Bourredjem A, Hernu R, Montini F, Bruyère R, et al. Timing of renal-replacement therapy in patients with acute kidney injury and sepsis. N Engl J Med. 2018;379(15):1431–1442. doi: 10.1056/NEJMoa1803213.
- Ye Z, Wang Y, Ge L, et al. Comparing renal replacement modalities in critically ill patients with acute kidney injury: a systematic review and network meta-analysis. Crit Care Explor. 2021;3:e0399. doi: 10.1097/CCE.0000000000000399.
- Vijayan A, Delos Santos RB, Li T, Goss CW, Palevsky PM. Effect of frequent dialysis on renal recovery: results from the acute renal failure trial network study. Kidney Int Rep. 2017;3:456–463. doi: 10.1016/j.ekir.2017.11.018.
- Gaudry S, Grolleau F, Barbar S, et al. Continuous renal replacement therapy versus intermittent hemodialysis as first modality for renal replacement therapy in severe acute kidney injury: a secondary analysis of AKIKI and IDEAL-ICU studies. Crit Care. 2022;26:93. doi: 10.1186/s13054-022-03955-9.
Source: PubMed