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

Vedat Schwenger, Markus A Weigand, Oskar Hoffmann, Ralf Dikow, Lars P Kihm, Jörg Seckinger, Nexhat Miftari, Matthias Schaier, Stefan Hofer, Caroline Haar, Peter P Nawroth, Martin Zeier, Eike Martin, Christian Morath, Vedat Schwenger, Markus A Weigand, Oskar Hoffmann, Ralf Dikow, Lars P Kihm, Jörg Seckinger, Nexhat Miftari, Matthias Schaier, Stefan Hofer, Caroline Haar, Peter P Nawroth, Martin Zeier, Eike Martin, Christian Morath

Abstract

Introduction: Acute kidney injury (AKI) is associated with a high mortality of up to 60%. The mode of renal replacement therapy (intermittent versus continuous) has no impact on patient survival. Sustained low efficiency dialysis using a single-pass batch dialysis system (SLED-BD) has recently been introduced for the treatment of dialysis-dependent AKI. To date, however, only limited evidence is available in the comparison of SLED-BD versus continuous veno-venous hemofiltration (CVVH) in intensive care unit (ICU) patients with AKI.

Methods: Prospective, randomized, interventional, clinical study at a surgical intensive care unit of a university hospital. Between 1 April 2006 and 31 January 2009, 232 AKI patients who underwent renal replacement therapy (RRT) were randomized in the study. Follow-up was assessed until 30 August 2009. Patients were either assigned to 12-h SLED-BD or to 24-h predilutional CVVH. Both therapies were performed at a blood flow of 100 to 120 ml/min.

Results: 115 patients were treated with SLED-BD (total number of treatments n = 817) and 117 patients with CVVH (total number of treatments n = 877).The primary outcome measure, 90-day mortality, was similar between groups (SLED: 49.6% vs. CVVH: 55.6%, P = 0.43). Hemodynamic stability did not differ between SLED-BD and CVVH, whereas patients in the SLED-BD group had significantly fewer days of mechanical ventilation (17.7 ± 19.4 vs. 20.9 ± 19.8, P = 0.047) and fewer days in the ICU (19.6 ± 20.1 vs. 23.7 ± 21.9, P = 0.04). Patients treated with SLED needed fewer blood transfusions (1,375 ± 2,573 ml vs. 1,976 ± 3,316 ml, P = 0.02) and had a substantial reduction in nursing time spent for renal replacement therapy (P < 0.001) resulting in lower costs.

Conclusions: SLED-BD was associated with reduced nursing time and lower costs compared to CVVH at similar outcomes. In the light of limited health care resources, SLED-BD offers an attractive alternative for the treatment of AKI in ICU patients.

Trial registration: ClinicalTrials.gov NCT00322530.

Figures

Figure 1
Figure 1
Enrolment, randomization and inclusion of study patients. Numbers of ICU patients enrolled in the study and randomly assigned to different treatment groups.
Figure 2
Figure 2
Probabilities of survival in sustained low efficiency dialysis (SLED) and continuous veno-venous hemofiltration (CVVH) treatment groups (Kaplan-Meier estimates) during the first 90 days. Mortality at 90 days was similar in ICU patients with acute kidney disease (AKI) treated with SLED-BD or with CVVH.

References

    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. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA. 2005;294:813–818. doi: 10.1001/jama.294.7.813.
    1. Bagshaw SM, Mortis G, Doig CJ, Godinez-Luna T, Fick GH, Laupland KB. One-year mortality in critically ill patients by severity of kidney dysfunction: a population-based assessment. Am J Kidney Dis. 2006;48:402–409. doi: 10.1053/j.ajkd.2006.06.002.
    1. Levy EM, Viscoli CM, Horwitz RI. The effect of acute renal failure on mortality. A cohort analysis. JAMA. 1996;275:1489–1494. doi: 10.1001/jama.1996.03530430033035.
    1. Ishani A, Xue JL, Himmelfarb J, Eggers PW, Kimmel PL, Molitoris BA, Collins AJ. Acute kidney injury increases risk of ESRD among elderly. J Am Soc Nephrol. 2009;20:223–228. doi: 10.1681/ASN.2007080837.
    1. Morgera S, Kraft AK, Siebert G, Luft FC, Neumayer HH. Long-term outcomes in acute renal failure patients treated with continuous renal replacement therapies. Am J Kidney Dis. 2002;40:275–279. doi: 10.1053/ajkd.2002.34505.
    1. Guerin C, Girard R, Selli JM, Ayzac L. Intermittent versus continuous renal replacement therapy for acute renal failure in intensive care units: results from a multicenter prospective epidemiological survey. Intensive Care Med. 2002;28:1411–1418. doi: 10.1007/s00134-002-1433-0.
    1. Lins RL, Elseviers MM, Van der Niepen P, Hoste E, Malbrain ML, Damas P, Devriendt J. 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. 2009;24:512–518.
    1. Vinsonneau C, Camus C, Combes A, Costa de Beauregard MA, Klouche K, Boulain T, Pallot JL, Chiche JD, Taupin P, Landais P, Dhainaut JF. Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial. Lancet. 2006;368:379–385. doi: 10.1016/S0140-6736(06)69111-3.
    1. Bellomo R, Cass A, Cole L, Finfer S, Gallagher M, Lo S, McArthur C, McGuinness S, Myburgh J, Norton R, Scheinkestel C, Su S. Intensity of continuous renal-replacement therapy in critically ill patients. N Engl J Med. 2009;361:1627–1638.
    1. 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.
    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. 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. Kielstein JT, Kretschmer U, Ernst T, Hafer C, Bahr MJ, Haller H, Fliser D. Efficacy and cardiovascular tolerability of extended dialysis in critically ill patients: a randomized controlled study. Am J Kidney Dis. 2004;43:342–349. doi: 10.1053/j.ajkd.2003.10.021.
    1. Lonnemann G, Floege J, Kliem V, Brunkhorst R, Koch KM. Extended daily veno-venous high-flux haemodialysis in patients with acute renal failure and multiple organ dysfunction syndrome using a single path batch dialysis system. Nephrol Dial Transplant. 2000;15:1189–1193. doi: 10.1093/ndt/15.8.1189.
    1. NCT 00322530.
    1. Dhondt A, Eloot S, Wachter DD, Smet RD, Waterloos MA, Glorieux G, Lameire N, Verdonck P, Vanholder R. Dialysate partitioning in the Genius batch hemodialysis system: effect of temperature and solute concentration. Kidney Int. 2005;67:2470–2476. doi: 10.1111/j.1523-1755.2005.00356.x.
    1. Fassbinder W. Experience with the GENIUS hemodialysis system. Kidney Blood Press Res. 2003;26:96–99. doi: 10.1159/000070990.
    1. Fliser D, Kielstein JT. A single-pass batch dialysis system: an ideal dialysis method for the patient in intensive care with acute renal failure. Curr Opin Crit Care. 2004;10:483–488. doi: 10.1097/01.ccx.0000145101.58940.dc.
    1. Hebert PC, Wells G, Blajchman MA, Marshall J, Martin C, Pagliarello G, Tweeddale M, Schweitzer I, Yetisir E. A multicenter, randomized, controlled clinical trial of transfusion requirements in critical care. Transfusion Requirements in Critical Care Investigators, Canadian Critical Care Trials Group. N Engl J Med. 1999;340:409–417. doi: 10.1056/NEJM199902113400601.
    1. Kellum JA, Ronco C. Dialysis: Results of RENAL--what is the optimal CRRT target dose? Nat Rev Nephrol. pp. 191–192.
    1. Klarenbach S, Manns B, Pannu N, Clement FM, Wiebe N, Tonelli M. Economic evaluation of continuous renal replacement therapy in acute renal failure. Int J Technol Assess Health Care. 2009;25:331–338. doi: 10.1017/S0266462309990134.
    1. Kumar VA, Craig M, Depner TA, Yeun JY. Extended daily dialysis: A new approach to renal replacement for acute renal failure in the intensive care unit. Am J Kidney Dis. 2000;36:294–300. doi: 10.1053/ajkd.2000.8973.
    1. Marshall MR, Golper TA, Shaver MJ, Alam MG, Chatoth DK. Sustained low-efficiency dialysis for critically ill patients requiring renal replacement therapy. Kidney Int. 2001;60:777–785. doi: 10.1046/j.1523-1755.2001.060002777.x.
    1. Tolwani AJ, Campbell RC, Stofan BS, Lai KR, Oster RA, Wille KM. Standard versus high-dose CVVHDF for ICU-related acute renal failure. J Am Soc Nephrol. 2008;19:1233–1238. doi: 10.1681/ASN.2007111173.
    1. Kielstein JT, Burkhardt O. Dosing of Antibiotics in Critically Ill Patients Undergoing Renal Replacement Therapy. Curr Pharm Biotechnol.
    1. Berbece AN, Richardson RM. Sustained low-efficiency dialysis in the ICU: cost, anticoagulation, and solute removal. Kidney Int. 2006;70:963–968. doi: 10.1038/sj.ki.5001700.
    1. Kuiper JW, Groeneveld AB, Slutsky AS, Plotz FB. Mechanical ventilation and acute renal failure. Crit Care Med. 2005;33:1408–1415. doi: 10.1097/01.CCM.0000165808.30416.EF.
    1. Alonso A, Lau J, Jaber BL. Biocompatible hemodialysis membranes for acute renal failure. Cochrane Database Syst Rev. 2008. p. CD005283.
    1. Ponikvar JB, Rus RR, Kenda RB, Bren AF, Ponikvar RR. Low-flux versus high-flux synthetic dialysis membrane in acute renal failure: prospective randomized study. Artif Organs. 2001;25:946–950. doi: 10.1046/j.1525-1594.2001.06753.x.
    1. Morath C, Miftari N, Dikow R, Hainer C, Zeier M, Morgera S, Weigand MA, Schwenger V. Sodium citrate anticoagulation during sustained low efficiency dialysis (SLED) in patients with acute renal failure and severely impaired liver function. Nephrol Dial Transplant. 2008;23:421–422.
    1. Dhondt AW, Vanholder RC, De Smet RV, Claus SA, Waterloos MA, Glorieux GL, Delanghe JR, Lameire NH. Studies on dialysate mixing in the Genius single-pass batch system for hemodialysis therapy. Kidney Int. 2003;63:1540–1547. doi: 10.1046/j.1523-1755.2003.00862.x.

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