Correlation between parameters at initiation of renal replacement therapy and outcome in patients with acute kidney injury

Marlies Ostermann, René Ws Chang, Marlies Ostermann, René Ws Chang

Abstract

Introduction: Renal replacement therapy (RRT) is a fully established treatment for critically ill patients with acute kidney injury (AKI) but there are no scientifically established criteria when to initiate it. Our objectives were to describe the epidemiology of critically ill patients with AKI receiving RRT and to evaluate the relationship between biochemical, physiological and comorbid factors at time of RRT and ICU mortality.

Methods: Retrospective analysis of demographic and physiologic data of 1,847 patients who received RRT for AKI in 22 ICUs in UK and Germany between 1989 - 1999.

Results: 54.1% of RRT patients died in ICU. ICU survivors were younger, had a lower APACHE II score and fewer failed organ systems on admission to ICU compared to non-survivors. Multivariate analysis showed that at time of initiation of RRT, independent risk factors for ICU mortality were mechanical ventilation [odds ratio (OR) 6.03], neurological failure (OR 2.48), liver failure (OR 2.44), gastrointestinal failure (OR 2.04), pre-existing chronic illnesses (OR 1.74), haematological failure (OR 1.74), respiratory failure (OR 1.62), oligoanuria (OR 1.6), age (OR 1.03), serum urea (OR 1.004) and cardiovascular failure (OR 1.3). A higher pH at initiation of RRT was independently associated with a better outcome. Failure to correct acidosis and development of more organ failure within 48 hours after initiation of RRT were also associated with an increased risk of dying in ICU.

Conclusions: Oligoanuria, acidosis and concomitant dysfunction of other organs at time of RRT were associated with poor survival. In contrast, serum creatinine and urea levels only had a weak correlation with outcome after RRT.

References

    1. Mehta RL, Pascual MT, Soroko S, Savage BR, Himmelfarb J, Ikizler TA, Paganini EP, Chertow GM. for the Program of Improve Care in Acute Renal Disease. Spectrum of acute renal failure in the intensive care unit: the PICARD experience. Kidney Int. 2004;66:1613–1621. doi: 10.1111/j.1523-1755.2004.00927.x.
    1. Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, Gibney N, Tolwani A, Ronco C. Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) Investigators. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA. 2005;294:813–818. doi: 10.1001/jama.294.7.813.
    1. Ostermann M, Chang RW. Correlation between the AKI classification and outcome. Crit Care. 2008;12:R144. doi: 10.1186/cc7123.
    1. Ostermann M, Chang RW. Acute kidney injury in the intensive care unit according to RIFLE. Crit Care Med. 2007;35:1837–1843. doi: 10.1097/01.CCM.0000277041.13090.0A.
    1. Overberger P, Pesacreta M, Palevsky PM. for the VA/NIH Acute Renal Failure Trial Network. Management of renal replacement therapy in acute kidney injury: a survey of practioner prescribing practices. Clin J Am Soc Nephrol. 2007;2:623–630. doi: 10.2215/CJN.00780207.
    1. Pannu N, Klarenbach S, Wiebe N, Manns B, Tonelli M. Alberta Kidney Disease Network. Renal replacement therapy in patients with acute renal failure: a systematic review. JAMA. 2008;299:793–805. doi: 10.1001/jama.299.7.793.
    1. Vesconi S, Cruz DN, Fumagalli R, Kindgen-Milles D, Monti G, Marinho A, Mariano F, Formica M, Marchesi M, Rene R, Livigni S, Ronco C. Dose Response Multicentre International collaborative Initiative (DO-RE-MI Study Group) Delivered dose of renal replacement therapy and mortality in critically ill patients with acute kidney injury. Crit Care. 2009;13:R57. doi: 10.1186/cc7784.
    1. Davenport A, Bouman C, Kirpalani A, Skippen P, Tolwani A, Mehta RL, Palevsky PM. Delivery of renal replacement therapy in acute kidney injury: What are the key issues? Clin J Am Soc Nephrol. 2008;3:869–875. doi: 10.2215/CJN.04821107.
    1. Liu KD, Himmelfarb J, Paganini E, Ikizler TA, Soroko SH, Mehta RL, Chertow GM. Timing of initiation of dialysis in critically ill patients with acute kidney injury. Clin J Am Soc Nephrol. 2006;1:915–919. doi: 10.2215/CJN.01430406.
    1. Gibney N, Hoste E, Burdmann EA, Bunchman T, Kher V, Viswanathan R, Mehta RL, Ronco C. Timing of initiation and discontinuation of renal replacement therapy in AKI: unanswered key questions. Clin J Am Soc Nephrol. 2008;3:876–880. doi: 10.2215/CJN.04871107.
    1. Bagshaw SM, Uchino S, Bellomo R, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, Gibney N, Tolwani A, Oudemans-van Straaten HM, Ronco C, Kellum JA. Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) Investigators. Timing of renal replacement therapy and clinical outcomes in critically ill patients with severe acute kidney injury. J Crit Care. 2009;24:129–140. doi: 10.1016/j.jcrc.2007.12.017.
    1. Seabra VF, Balk EM, Liangos O, Sosa MA, Cendoroglo M, Jaber BL. Timing of renal replacement therapy initiation in acute renal failure: a meta-analysis. Am J Kidney Dis. 2008;52:272–284. doi: 10.1053/j.ajkd.2008.02.371.
    1. Kellum JA, Mehta RL, Levin A, Molitoris BA, Warnock DG, Shah SV, Joannidis M, Ronco C. for the Acute Kidney Injury Network (AKIN) Development of a clinical research agenda for acute kidney injury using an international interdisciplinary three-step modified Delphi process. Clin J Am Soc Nephrol. 2008;3:887–894. doi: 10.2215/CJN.04891107.
    1. Mehta RL, Kellum JA, Shah SV, Molitoris BA, Ronco C, Warnock DG, Levin A. Acute Kidney Injury Network (AKIN): report of an initiative to improve outcomes in acute kidney injury. Critical Care. 2007;11:R31. doi: 10.1186/cc5713.
    1. Knaus WA, Draper EA, Wagner DP, Zimmermann JE. Prognosis in acute organ-system failure. Ann Surg. 1985;202:685–693. doi: 10.1097/00000658-198512000-00004.
    1. Chang RWS, Jacobs S, Lee B. Gastrointestinal dysfunction among intensive care unit patients. Crit Care Med. 1987;15:909–914. doi: 10.1097/00003246-198710000-00003.
    1. Palevsky PM. Clinical review: Timing and dose of continuous renal replacement therapy in acute kidney injury. Crit Care. 2007;11:232. doi: 10.1186/cc6121.
    1. Bouman CS, Oudemans-Van Straaten HM, Tijssen JG, Zandstra DF, Kesecioglu J. Effects of early high-volume continuous veno-venous hemofiltration on survival and recovery of renal function in intensive care patients with acute renal failure: a prospective, randomized trial. Crit Care Med. 2002;30:2205–2211. doi: 10.1097/00003246-200210000-00005.
    1. Pursnani ML, Hazra DK, Singh B, Pandey DN. Early haemodialysis in acute tubular necrosis. J Assoc Physicians India. 1997;45:850–852.
    1. Durmaz I, Yagdi T, Calkavur T, Mahmudov R, Apaydin AZ, Posacioglu H, Atay Y, Engin C. Prophylactic dialysis in patients with renal dysfunction undergoing on-pump coronary artery bypass surgery. Ann Thorac Surg. 2003;75:859–864. doi: 10.1016/S0003-4975(02)04635-0.
    1. Koo JR, Yoon JW, Oh JE. Prospective evaluation of early continuous venovenous haemofiltration on the outcome in patients with severe sepsis or septic shock. J Am Soc Nephrol. 2006;17:50A. abstract.
    1. Mehta RL, Pascual MT, Gruta CG, Zhuang S, Chertow GM. for the PICARD Study Group. Refining predictive models in critically ill patients with acute renal failure. J Am Soc Nephrol. 2002;13:1350–1357. doi: 10.1097/01.ASN.0000014692.19351.52.
    1. Paganini EP, Halstenberg WK, Goormastic M. Risk modelling in acute renal failure requiring dialysis: The introduction of a new model. Clin Nephrol. 1996;46:206–211.
    1. Maccariello E, Rocha E, Valente C, Nogueira L, Rocha PT, Bonomo H Jr, Serpa LF, Ismael M, Valença RV, Machado JE, Soares M. Effects of early changes in organ dysfunction on the outcomes of critically ill patients in need of renal replacement therapy. Clinics. 2008;63:343–350. doi: 10.1590/S1807-59322008000300010.
    1. VA/NIH Acute Renal Failure Trial Network. 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. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. 2008;359:7–20. doi: 10.1056/NEJMoa0802639.
    1. The RENAL Replacement Therapy Study Investigators. Intensity of continuous renal replacement therapy in critically ill patients. N Engl J Med. 2009;361:1627–1638. doi: 10.1056/NEJMoa0902413.

Source: PubMed

Sponsors en medewerkers

Medische omstandigheden

Geneesmiddelinterventies

3
Abonneren