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Early vs late renal replacement therapy (RRT)

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A talk by Johan Mårtensson at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine.

All available content from SSAI2017: https://scanfoam.org/ssai2017/

Delivered in collaboration between scanFOAM, SSAI & SFAI.

Publicado en: Atención sanitaria
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Early vs late renal replacement therapy (RRT)

  1. 1. Earlier vs Later Renal Replacement Therapy (RRT) Johan Mårtensson
  2. 2. Conflict of interest: None
  3. 3. Time for RRT? –Yes! Mr. Jones, 58 yr Day 4 in ICU Severe sepsis Fluid balance ++++ FiO2 0.7 S-creatinine 540 µmol/L Urea 40 mmol/L S-K+ 6.2 mmol/L Urine output 20 mL/hour (lasix infusion 40 mg/hr)
  4. 4. ”Late” RRT ”Conventional” or ”absolute” indications for RRT in AKI: • Refractory hyperkalemia (e.g. K+ >6) • Refractory acidemia & metabolic acidosis (e.g. pH <7.2) • Refractory pulmonary edema due to fluid overload • Uremic complications (e.g. bleeding, pericarditis) • Overdose/toxicity from a dialyzable drug/toxin
  5. 5. Contemporary AKI staging KDIGO stage Plasma creatinine Urine output 1 1.5-2 times baseline OR >26.5 µmol/l increase <0.5 ml/kg/h for 6-12 h 2 2.0-2.9 times baseline <0.5 ml/kg/h for ≥12 h 3 3.0 times baseline OR Increase to ≥354 µmol/l <0.3 ml/kg/h for ≥24 h OR Anuria for ≥12 h the Kidney Disease Improving Global Outcomes (KDIGO) guidelines
  6. 6. The AKIKI trial
  7. 7. AKIKI setup 620 pts, 31 ICUs • KDIGO stage 3 AKI • Mechanical ventilation and/or catecholamine infusion • No absolute indication Early Group (n=311) Start RRT immediately Late Group (n=308) Start RRT if: Absolute indication OR Oliguria >72 hrs
  8. 8. AKIKI treatmentRandomisation 2 hours 57 h 0 20 40 60 80 100%receivingRRT Early Late 49% no RRT 51% RRT ≥1 absolute indication (82%) Oliguria >72 h (18%)
  9. 9. AKIKI 60-day mortality P=0.79 0 20 40 6060-daymortality,% Early Late
  10. 10. AKIKI secondary outcomes P=0.12 0 2 4 6 8 10 DependenceonRRTday60,% Early Late P=0.03 0 5 10 15 20 Catheter-relatedbloodstreaminfection,% Early Late
  11. 11. The ELAIN trial
  12. 12. ELAIN setup 231 pts (mainly post-surgical), single-center • KDIGO stage 2 AKI • Plasma Neutrophil gelatinase-associated lipocalin (NGAL) >150 ng/ml • Any of the following: • Severe sepsis • Vasoactive support • Fluid overload • Worsening SOFA score Early Group (n=112) RRT within 8 h from KDIGO 2 Late Group (n=119) RRT within 12 h from KDIGO 3 OR Absolute indication
  13. 13. ELAIN treatment Randomisation 6 hours 26 hours 0 20 40 60 80 100 %receivingRRT Early Late 9% no RRT 91% RRT -KDIGO 3 (84%) -Absolute indication (16%)
  14. 14. ELAIN 90-day mortality P=0.03 0 20 40 60 90-daymortality,% Early Late
  15. 15. ELAIN renal recovery P=0.62 0 20 40 60 80 100 meanofrecovery90surv Early Late Survivors P=0.02 0 20 40 60 80 100 Renalrecoveryday90,% Early Late All patients
  16. 16. Other factors affecting decision making • Anticipation of worsening kidney function • Worsening nonrenal organ dysfunction • Expected high solute burden (e.g. tumor lysis syndrome) • Facilitate other supportive measures (nutrition, drugs, other fluids) • Perception of benefit
  17. 17. * * Treating clinician must confirm clinical equipoise
  18. 18. Take-home message • No strong evidence that ”early” RRT will improve outcomes • ”Early” RRT may expose some patients to unnecessary treatment • Timing based on patient characteristics, illness severity and trends in physiology/biochemistry

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