Chirag R. Parikh, MD, PhD; Justin Belcher, MD
In critically ill patients with acute kidney injury, what is the relative effectiveness of higher-intensity and lower-intensity continuous renal-replacement therapy (RRT) for reducing mortality?
Randomized controlled trial (Randomized Evaluation of Normal versus Augmented Level [RENAL] Replacement Therapy Study). ClinicalTrials.gov NCT00221013.
35 intensive care units in Australia and New Zealand.
1508 critically ill patients ≥ 18 years of age who had acute kidney injury, required RRT, and met ≥ 1 of the following criteria: oliguria that was unresponsive to fluid resuscitation, serum potassium level > 6.5 mmol/L, severe acidemia, plasma urea nitrogen level > 25 mmol/L, serum creatinine level > 300 µmol/L, and clinically significant organ edema. Exclusion criteria included previous RRT during the same admission and maintenance dialysis for end-stage kidney disease. 1465 patients provided consent and were enrolled (mean age 65 y, 65% men).
Continuous venovenous hemodiafiltration with effluent flow set at 40 mL/kg/h (higher intensity, n = 747) or 25 mL/kg/h (lower intensity, n = 761). Replacement fluid was delivered into the extracorporeal circuit postdilution with a 1:1 ratio of dialysate to replacement fluid. Blood flow was > 150 mL/min. Fluid was removed by decreasing flow of replacement fluid and dialysate in equal proportions, such that effluent exceeded both by an amount determined by the clinician.
Mortality at 90 days. Secondary outcomes included RRT dependence at 90 days, hypophosphatemia, and other serious adverse events. A sample size of 1500 would have given the trial 90% power to detect an 8.5% absolute reduction in 90-day mortality (α < 0.05).
97% (intention-to-treat analysis).
Higher- and lower-intensity RRT did not differ for mortality or dependence on RRT at 90 days (Table). Risk for hypophosphatemia (Table), but not other serious adverse events, was increased in the higher-intensity group.
In critically ill patients with acute kidney injury, higher- and lower-intensity renal-replacement therapy resulted in similar rates of mortality.
Higher- vs lower-intensity continuous renal-replacement therapy (RRT) in critically ill patients with acute kidney injury†
†Abbreviations defined in Glossary. RRI, NNH, and CI calculated from data in article.
Chirag R. Parikh, Justin Belcher. Higher-intensity continuous renal-replacement therapy did not reduce mortality in critically ill patients with kidney injury. Ann Intern Med. 2010;152:JC2–5. doi: 10.7326/0003-4819-152-4-201002160-02005
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Published: Ann Intern Med. 2010;152(4):JC2-5.
Emergency Medicine, Nephrology, Pulmonary/Critical Care, Urological Disorders.
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