Systematic review and meta-analysis of renal replacement therapy modalities for acute kidney injury in the intensive care unit.

To compare clinical outcomes among critically ill adults with acute kidney injury (AKI) treated with continuous renal replacement therapy (CRRT), intermittent hemodialysis (IHD) or sustained low efficiency dialysis (SLED). We completed a systematic review and meta-analysis of studies published in 2015 or earlier using MEDLINE®, EMBASE®, Cochrane databases and grey literature. Eligible studies included randomized clinical trials (RCTs) or prospective cohort studies comparing outcomes of mortality, dialysis dependence or length of stay among critically ill adults receiving CRRT, IHD or SLED to treat AKI. Mortality and dialysis dependence from RCTs were pooled using meta-analytic techniques. Length of stay from RCTs and results from prospective cohort studies were described qualitatively. Twenty-one studies were eligible. RRT modality was not associated with in-hospital mortality (CRRT vs IHD: RR 1.00 [95% CI, 0.92-1.09], CRRT vs SLED: RR 1.23 [95% CI, 1.00-1.51]) or dialysis dependence (CRRT vs IHD: RR 0.90 [95% CI, 0.59-1.38], CRRT vs SLED: RR 1.15 [95% CI, 0.67-1.99]). We did not find a definitive advantage for any RRT modality on short-term patient or kidney survival. Well-designed, adequately-powered trials are needed to better define the role of RRT modalities for treatment of critically ill patients with AKI.

Nash DM ，Przech S ，Wald R ，O'Reilly D ... -  《-》

Renal replacement therapy in the ICU: intermittent hemodialysis, sustained low-efficiency dialysis or continuous renal replacement therapy?

Wang AY ，Bellomo R 《-》

Initial renal replacement therapy (RRT) modality associates with 90-day postdischarge RRT dependence in critically ill AKI survivors.

Real-world comparison of RRT modality on RRT dependence at 90 days postdischarge among ICU patients discharged alive after RRT for acute kidney injury (AKI). Using claims-linked to US hospital discharge data (Premier PINC AI Healthcare Database [PHD]), we compared continuous renal replacement therapy (CRRT) vs. intermittent hemodialysis (IHD) for AKI in adult ICU patients discharged alive from January 1, 2018 to June 30, 2021. RRT dependence at 90 days postdischarge was defined as ≥2 RRT treatments in the last 8 days. Between-group differences were balanced using inverse probability treatment weighting (IPTW). Of 34,804 patients, 3804 patients (from 382 hospitals) had claims coverage for days 83-90 postdischarge. Compared to IHD-treated patients (n = 2740), CRRT-treated patients (n = 1064) were younger; had more admission to large teaching hospitals, surgery, sepsis, shock, mechanical ventilation, but lower prevalence of comorbidities (p < 0.05 for all). Compared to IHD-treated patients, CRRT-treated patients had lower RRT dependence at hospital discharge (26.5% vs. 29.8%, p = 0.04) and lower RRT dependence at 90 days postdischarge (4.9% vs. 7.4% p = 0.006) with weighted adjusted OR (95% CI): 0.68 (0.47-0.97), p = 0.03. Results persisted in sensitivity analyses including patients who died during days 1-90 postdischarge (n = 112) or excluding patients from hospitals with IHD patients only (n = 335), or when excluding patients who switched RRT modalities (n = 451). Adjusted for potential confounders, the odds of RRT dependence at 90 days postdischarge among survivors of RRT for AKI was 30% lower for those treated first with CRRT vs. IHD, overall and in several sensitivity analyses. Critically ill patients in intensive care units (ICU) may develop acute kidney injury (AKI) that requires renal replacement therapy (RRT) to temporarily replace the injured kidney function of cleaning the blood. Two main types of RRT in the ICU are called continuous renal replacement therapy (CRRT), which is performed almost continuously, i.e., for >18 h per day, and intermittent hemodialysis (IHD), which is a more rapid RRT that is usually completed in a little bit over 6 h, several times per week. The slower CRRT may be gentler on the kidneys and is more likely to be used in the sickest patients, who may not be able to tolerate IHD. We conducted a data-analysis study to evaluate whether long-term effects on kidney function (assessed by ongoing need for RRT, i.e., RRT dependence) differ depending on use of CRRT vs. IHD. In a very large US linked hospital-discharge/claims database we found that among ICU patients discharge alive after RRT for AKI, fewer CRRT-treated patients had RRT dependence at hospital discharge (26.5% vs. 29.8%, p = 0.04) and at 90 days after discharge (4.9% vs. 7.4% p = 0.006). In adjusted models, RRT dependence at 90 days postdischarge was >30% lower for CRRT than IHD-treated patients. These results from a non-randomized study suggest that among survivors of RRT for AKI, CRRT may result in less RRT dependence 90 days after hospital discharge.

Koyner JL ，Mackey RH ，Echeverri J ，Rosenthal NA ，Carabuena LA ，Bronson-Lowe D ，Harenski K ，Neyra JA ... -  《-》

Estimating the impact of renal replacement therapy choice on outcome in severe acute renal failure.

Swartz RD ，Bustami RT ，Daley JM ，Gillespie BW ，Port FK ... -  《CLINICAL NEPHROLOGY》

Extended Daily Dialysis Versus Continuous Renal Replacement Therapy for Acute Kidney Injury: A Meta-analysis.

Extended daily dialysis (EDD) has been suggested as an effective renal replacement therapy for acute kidney injury. However, results from studies comparing EDD to continuous renal replacement therapy (CRRT) are inconclusive. A systematic review and meta-analysis was performed by searching in MEDLINE, EMBASE, the Cochrane Library, Google Scholar, and a Chinese database (SinsoMed). Patients with acute kidney injury. Randomized controlled trials (RCTs) and observational studies were included. EDD was defined as extended hemodialysis or hemodiafiltration for more than 6 but less than 24 hours per session using a conventional hemodialysis machine. Renal replacement therapy comparing EDD with CRRT. Mortality, kidney recovery, and fluid removal. We included 17 studies from 2000 to 2014: 7 RCTs and 10 observational studies involving 533 and 675 patients, respectively. Meta-analysis of RCTs showed no difference in mortality rates between EDD and CRRT (relative risk, 0.90; 95% CI, 0.74-1.11; P=0.3). However, EDD was associated with lower mortality risk compared with CRRT in observational studies (relative risk, 0.86; 95% CI, 0.74-1.00; P=0.05). There was no evidence of heterogeneity in RCTs (I(2)=0%) or observational studies (I(2)=15%). In both RCTs and observational studies, there were no significant differences in recovery of kidney function, fluid removal, or days in the intensive care unit, and EDD showed similar biochemical efficacy to CRRT during treatment (serum urea, serum creatinine, and serum phosphate). The survival benefit of EDD is dependent on only observational studies and might have been affected by allocation or selection bias. EDD is associated with similar outcomes to CRRT in RCTs. The finding that EDD is associated with a lower mortality rate relies on data from observational studies, which are potentially subject to allocation or selection bias, making further high-quality RCTs desirable.

Zhang L ，Yang J ，Eastwood GM ，Zhu G ，Tanaka A ，Bellomo R ... -  《-》