Nephrology Critical Care

Ronco C, Ricci Z, De Backer D, et al. Renal replacement therapy in acute kidney injury: controversy and consensus. Crit Care 2015; 19: 146. A review of strategies for RRT in the ICU, including modalities, adverse effects, and approaches for specific clinical situations.

PMID: 25887923

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Vinsonneau C, Camus C, Combes A, et al. Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome. Lancet 2006; 368 :379-85. Like previous RCTs addressing this issue, this multicenter study of 360 ICU patients found no advantage to continuous venovenous dialysis in terms of 60-day survival. A limitation of the study is that the delivered dialysis dose may have been suboptimal for both arms.

PMID: 16876666

Bagshaw SM, Wald R, Adhikari NKJ, et al. Timing of initiation of renal replacement therapy in acute kidney injury. STARRT-AKI Investigators.  N Engl J Med. 2020; 383:240-251. This multicenter RCT of nearly 3,000 patients is the latest to show no mortality benefit to early initiation of dialysis in patients with AKI but no emergent need for dialysis. As with previous studies, patients in the early dialysis group experienced more adverse events and were more likely to be dialysis dependent at 90 days. Unlike similar preceding trials, clinical equipoise on the part of the treating provider was also required for enrollment.

PMID: 32668114

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Gaudry S, Hajage D, Martin-Lefevre L, et al. Comparison of two delayed strategies for renal replacement therapy initiation for severe acute kidney injury (AKIKI 2): a multicentre, open-label, randomised, controlled trial. Lancet. 2021; 397:1293-1300. This trial compared maximal delay in initiating HD (waiting until an absolute indication or BUN > 140 mg/dl) to initiating HD for oliguria present > 72 hours or BUN > 112 mg/dl.  More patients in the maximal-delay group avoided HD (21 vs. 2%), but there was no difference in days free of renal replacement therapy and a multivariable analysis found reduced risk of death in the less-delayed group.

PMID: 33812488 

Semler MW, Self WH, Wanderer JP et al.  Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018; 378:829-839. A cluster-randomized, multiple-crossover, single-center trial of nearly 16,000 patients compared the effect of saline (0.9% sodium chloride) vs balanced crystalloids (lactated ringer's solution or Plasma-Lyte A) on a composite endpoint of death from any cause, new renal-replacement therapy, and persistent renal dysfunction. The composite endpoint was reached in 14.3% in the balanced-crystalloids group vs. 15.4% in the saline group (p = 0.04).  There was a trend toward a small improvement in mortality in the balanced crystalloid group (2.5 vs 2.9%).

PMID: 29485925

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Zampieri FG, Machado FR, Biondi RS, et al. Effect of intravenous fluid treatment with a balanced solution vs 0.9% saline solution on mortality in critically ill patients: the BaSICS randomized clinical trial. JAMA 2021;326:1-12. This large, multicenter trial found no difference between fluid choices in 90-day mortality or need for renal replacement and subgroup analysis revealed worse outcome with use of balanced crystalloids in patients with traumatic brain injury. Of note, nearly 50% of patients were admitted for elective surgery, 45% had received > 1 liter of fluids prior to enrollment, and patients received a median of only 1.5 L of fluid in the first 24 hours after enrollment. See also the 2022 PLUS Study.

PMID: 34375394

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