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Multicenter Study
. 2009;13(2):R57.
doi: 10.1186/cc7784. Epub 2009 Apr 15.

Delivered dose of renal replacement therapy and mortality in critically ill patients with acute kidney injury

Sergio Vesconi  1 , Dinna N Cruz, Roberto Fumagalli, Detlef Kindgen-Milles, Gianpaola Monti, Anibal Marinho, Filippo Mariano, Marco Formica, Mariano Marchesi, Robert René, Sergio Livigni, Claudio Ronco; DOse REsponse Multicentre International collaborative Initiative (DO-RE-MI Study Group)
Collaborators, Affiliations
Multicenter Study

Delivered dose of renal replacement therapy and mortality in critically ill patients with acute kidney injury

Sergio Vesconi et al. Crit Care. 2009.

Abstract

Introduction: The optimal dialysis dose for the treatment of acute kidney injury (AKI) is controversial. We sought to evaluate the relationship between renal replacement therapy (RRT) dose and outcome.

Methods: We performed a prospective multicentre observational study in 30 intensive care units (ICUs) in eight countries from June 2005 to December 2007. Delivered RRT dose was calculated in patients treated exclusively with either continuous RRT (CRRT) or intermittent RRT (IRRT) during their ICU stay. Dose was categorised into more-intensive (CRRT >or= 35 ml/kg/hour, IRRT >or= 6 sessions/week) or less-intensive (CRRT < 35 ml/kg/hour, IRRT < 6 sessions/week). The main outcome measures were ICU mortality, ICU length of stay and duration of mechanical ventilation.

Results: Of 15,200 critically ill patients admitted during the study period, 553 AKI patients were treated with RRT, including 338 who received CRRT only and 87 who received IRRT only. For CRRT, the median delivered dose was 27.1 ml/kg/hour (interquartile range (IQR) = 22.1 to 33.9). For IRRT, the median dose was 7 sessions/week (IQR = 5 to 7). Only 22% of CRRT patients and 64% of IRRT patients received a more-intensive dose. Crude ICU mortality among CRRT patients were 60.8% vs. 52.5% (more-intensive vs. less-intensive groups, respectively). In IRRT, this was 23.6 vs. 19.4%, respectively. On multivariable analysis, there was no significant association between RRT dose and ICU mortality (Odds ratio (OR) more-intensive vs. less-intensive: CRRT OR = 1.21, 95% confidence interval (CI) = 0.66 to 2.21; IRRT OR = 1.50, 95% CI = 0.48 to 4.67). Among survivors, shorter ICU stay and duration of mechanical ventilation were observed in the more-intensive RRT groups (more-intensive vs. less-intensive for all: CRRT (median): 15 (IQR = 8 to 26) vs. 19.5 (IQR = 12 to 33.5) ICU days, P = 0.063; 7 (IQR = 4 to 17) vs. 14 (IQR = 5 to 24) ventilation days, P = 0.031; IRRT: 8 (IQR = 5.5 to 14) vs. 18 (IQR = 13 to 35) ICU days, P = 0.008; 2.5 (IQR = 0 to 10) vs. 12 (IQR = 3 to 24) ventilation days, P = 0.026).

Conclusions: After adjustment for multiple variables, these data provide no evidence for a survival benefit afforded by higher dose RRT. However, more-intensive RRT was associated with a favourable effect on ICU stay and duration of mechanical ventilation among survivors. This result warrants further exploration.

Trial registration: Cochrane Renal Group (CRG110600093).

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Figures

Figure 1
Figure 1
Profile of study population. Calculation of RRT dose was performed on patients who were treated exclusively on one RRT schedule (CRRT only or IRRT only). Forty six patients were treated with mixed RRT schedules (CRRT + CPFA, n = 10; CRRT + IRRT, n = 36; see text for explanation). AKI = acute kidney injury; CKD = chronic kidney disease; CPFA = coupled plasmafiltration adsorption; CRRT = continuous renal replacement therapy; ESRD = end-stage renal disease; ICU = intensive care unit; IRRT = intermittent renal replacement therapy.
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Comment in

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