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. 2017 Dec 28;21(1):326.
doi: 10.1186/s13054-017-1903-y.

Timing of renal replacement therapy and long-term risk of chronic kidney disease and death in intensive care patients with acute kidney injury

Søren Christiansen  1 , Steffen Christensen  2 , Lars Pedersen  3 , Henrik Gammelager  3   4 , J Bradley Layton  5 , M Alan Brookhart  5 , Christian Fynbo Christiansen  3
Affiliations

Timing of renal replacement therapy and long-term risk of chronic kidney disease and death in intensive care patients with acute kidney injury

Søren Christiansen et al. Crit Care. .

Abstract

Background: The optimal time to initiate renal replacement therapy (RRT) in intensive care unit (ICU) patients with acute kidney injury (AKI) is unclear. We examined the impact of early RRT on long-term mortality, risk of chronic kidney disease (CKD), and end-stage renal disease (ESRD).

Methods: This cohort study included all adult patients treated with continuous RRT in the ICU at Aarhus University Hospital, Skejby, Denmark (2005-2015). Data were obtained from a clinical information system and population-based registries. Early treatment was defined as RRT initiation at AKI stage 2 or below, and late treatment was defined as RRT initiation at AKI stage 3. Inverse probability of treatment (IPT) weights were computed from propensity scores. The IPT-weighted cumulative risk of CKD (estimated glomerular filtration rate < 60 ml/minute/1.73 m2), ESRD, and mortality was estimated and compared using IPT-weighted Cox regression.

Results: The mortality, CKD, and ESRD analyses included 1213, 303, and 617 patients, respectively. The 90-day mortality in the early RRT group was 53.6% compared with 46.0% in the late RRT group (HR 1.24, 95% CI 1.03-1.48). The 90-day to 5-year mortality was 37.7% and 41.5% in the early and late RRT groups, respectively (HR 0.95, 95% CI 0.70-1.29). The 5-year risk of CKD was 35.9% in the early RRT group and 44.9% in the late RRT group (HR 0.74, 95% CI 0.46-1.18). The 5-year risk of ESRD was 13.3% in the early RRT group and 16.7% in the late RRT group (HR 0.79, 95% CI 0.47-1.32).

Conclusions: Early initiation was associated with increased 90-day mortality. In patients surviving to day 90, early initiation was not associated with a major impact on long-term mortality or risk of CKD and ESRD. Despite potential residual confounding due to the observational design, our findings do not support that early RRT initiation is superior to late initiation.

Keywords: Acute kidney injury; Chronic kidney disease; End-stage renal disease; Renal replacement therapy; Timing.

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Conflict of interest statement

Ethics approval and consent to participate

The study was approved by the Danish Data Protection Agency (record number 2015-57-0002, Aarhus University record number 2016-051-000001-432). No consent for patient participation was needed.

Consent for publication

No consent for publication was needed.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Flowchart of eligible patients included in the analyses. CKD Chronic kidney disease, DNPR Danish National Patient Registry, ESRD End-stage renal disease, RRT Renal replacement therapy
Fig. 2
Fig. 2
Inverse probability of treatment-weighted cumulative mortality for 0 to 90 days, HR 1.24 (95% CI 1.03–1.48); for 90 days to 5 years, HR 0.95 (95% CI 0.70–1.29). RRT Renal replacement therapy
Fig. 3
Fig. 3
Inverse probability of treatment-weighted cumulative risk of chronic kidney disease for 90 days to 5 years, HR 0.74 (95% CI 0.46–1.18). CKD Chronic kidney disease, RRT Renal replacement therapy
Fig. 4
Fig. 4
Inverse probability of treatment-weighted cumulative risk of end-stage renal disease for 90 days to 5 years, HR 0.79 (95% CI 0.47–1.32). ESRD End-stage renal disease, RRT Renal replacement therapy
See this image and copyright information in PMC

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