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"Intensity of Renal Support in Critically Ill Patients with Acute Kidney Injury".The New England Journal of Medicine. 2008. 359(1):7-20.PubMed•Full text•PDF

1 Clinical Question
2 Bottom Line
3 Major Points
4 Guidelines
5 Design
6 Population
6.1 Inclusion Criteria
6.2 Exclusion Criteria
6.3 Baseline Characteristics
7 Interventions
8 Outcomes
8.1 Primary Outcomes
8.2 Secondary Outcomes
9 Criticisms
10 Funding
11 Further Reading

Clinical Question

Does intensive renal support in critically ill patients with acute kidney injury decrease mortality, improve recovery of kidney function, or reduce the rate of nonrenal organ failure as compared with less-intensive therapy?

Bottom Line

Intensive renal support in critically ill patients with acute kidney injury did not decrease mortality, improve recovery of kidney function, or reduce the rate of nonrenal organ failure as compared with less-intensive therapy.

Major Points

This multicenter, randomized controlled trial found no benefit from intensive renal support over less-intensive therapy in critically ill patients with acute kidney injury. Intensive therapy was not associated with decreased 60-day mortality, improved recovery of kidney function, or reduced rate of nonrenal organ failure.

Guidelines

Not specifically addressed in the guidelines available at the time. Future guidelines may incorporate these findings.

Design

Mulycenter, prospective, randomized, parallel-group trial of two strategies for renal-replacement therapy in critically ill patients with acute kidney injury.
N=1,124 patients

Interventions:

- Intensive therapy: Intermitent hemodialysis and sustained low-efficiency dialysis six times per week, and continuous venovenous hemodiafiltration at 35 ml/kg/hour.
- Less-intensive therapy: Corresponding treatments provided thrice weekly and at 20 ml/kg/hour.
Setting: 27 VA and university-affiliated medical centers
Enrollment: November 2003 - July 2007
Analysis: Intention-to-treat
Primary efficacy outcome: Death from any cause by day 60
Primary safety outcome: Treatment-associated hypotension requiring intervention.

Population

Inclusion Criteria: Critically ill adults (≥18 years) with acute kidney injury clinically consistent with acute tubular necrosis requiring renal-replacement therapy, as well as failure of one or more nonrenal organ systems or sepsis.
Exclusion Criteria: Chronic kidney disease and other specific criteria
Baseline Characteristics: Similar between groups

Interventions

Patients underwent intermittent hemodialysis when hemodynamically stable and continuous venovenous hemodiafiltration or sustained low-efficiency dialysis when unstable. The choice of continuous venovenous hemodiafiltration or sustained low-efficiency dialysis was determined by site-specific practice.

Outcomes

Primary Outcomes
- Intensive therapy: 53.6% mortality
- Less-intensive therapy: 51.5% mortality (odds ratio, 1.09; 95% CI, 0.86 to 1.40; P=0.47)
Secondary Outcomes
- No significant differences in recovery of kidney function, duration of renal-replacement therapy, or evolution of nonrenal organ failure between groups.

Criticisms

- Timing of initiation of renal-replacement therapy not strictly standardized.
- Overrepresentation of men in the study population.
- Exclusion of patients with advanced chronic kidney disease limits generalizability.
- Intensity of therapy defined primarily by removal of small solutes without consideration for volume management.

Funding

Supported by the Cooperative Studies Program of the Department of Veterans Affairs Office of Research and Development and by the National Institute of Diabetes and Digestive and Kidney Diseases.

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