Continuous renal replacement therapy outcomes in acute kidney injury and end-stage renal disease: a cohort study

Critical Care

Ishir Bhan¹  John L Niles¹  Ednan Bajwa²  Jo Ann David-Kasdan¹  David JR Steele¹  Andrew S Allegretti³ 

[1] Divsion of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA;Divsion of Pulmonary and Critical Care Medicine, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA;Department of Medicine, Massachusetts General Hospital, Boston, MA, USA

关键词: dialysis-free survival;    dialysis;    end stage renal disease;    acute kidney injury;    mortality;    continuous renal replacement therapy;   

Others  :  818123
DOI  :  10.1186/cc12780

 received in 2013-06-13, accepted in 2013-06-20,  发布年份 2013

【 摘 要 】

Introduction

Continuous renal replacement therapy (CRRT) is a widely used but resource-intensive treatment. Despite its broad adoption in intensive care units (ICUs), it remains challenging to identify patients who would be most likely to achieve positive outcomes with this therapy and to provide realistic prognostic information to patients and families.

Methods

We analyzed a prospective cohort of all 863 ICU patients initiated on CRRT at an academic medical center from 2008 to 2011 with either new-onset acute kidney injury (AKI) or pre-admission end-stage renal disease (ESRD). We examined in-hospital and post-discharge mortality (for all patients), as well as renal recovery (for AKI patients). We identified prognostic factors for both in-hospital and post-discharge mortality separately in patients with AKI or ESRD.

Results

In-hospital mortality was 61% for AKI and 54% for ESRD. In patients with AKI (n = 725), independent risk factors for mortality included age over 60 (OR 1.9, 95% CI 1.3, 2.7), serum lactate over 4 mmol/L (OR 2.2, 95% CI 1.5, 3.1), serum creatinine over 3 mg/dL at time of CRRT initiation (OR 0.63, 95% CI 0.43, 0.92) and comorbid liver disease (OR 1.75, 95% CI 1.1, 2.9). Among patients with ESRD (n = 138), liver disease was associated with increased mortality (OR 3.4, 95% CI 1.1, 11.1) as was admission to a medical (vs surgical) ICU (OR 2.2, 95% CI 1.1, 4.7). Following discharge, advanced age became a predictor of mortality in both groups (AKI: HR 1.9, 95% CI 1.2, 3.0; ESRD: HR 4.1, 95% CI 1.5, 10.9). At the end of the study period, only 25% (n = 183) of patients with AKI achieved dialysis-free survival.

Conclusions

Among patients initiating CRRT, risk factors for mortality differ between patients with underlying ESRD or newly acquired AKI. Long-term dialysis-free survival in AKI is low. Providers should consider these factors when assessing prognosis or appropriateness of CRRT.

【 授权许可】

   
2013 Allegretti et al.; licensee BioMed Central Ltd.

【 图 表 】

Figure 1.

【 参考文献 】

• [1]Manns B, Doig CJ, Lee H, Dean S, Tonelli M, Johnson D, Donaldson C: Cost of acute renal failure requiring dialysis in the intensive care unit: clinical and resource implications of renal recovery. Crit Care Med 2003, 31:449-455.
• [2]Srisawat N, Lawsin L, Uchino S, Bellomo R, Kellum JA, BEST Kidney Investigators: Cost of acute renal replacement therapy in the intensive care unit: results from The Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) study. Crit Care 2010, 14:R46. BioMed Central Full Text
• [3]Bell M, Granath F, Schon S, Lofberg E, Ekbom A, Martling CR: End-stage renal disease patients on renal replacement therapy in the intensive care unit: short- and long-term outcome. Crit Care Med 2008, 36:2773-2778.
• [4]Sasaki S, Gando S, Kobayashi S, Nanzaki S, Ushitani T, Morimoto Y, Demmotsu O: Predictors of mortality in patients treated with continuous hemodiafiltration for acute renal failure in an intensive care setting. ASAIO J 2001, 47:86-91.
• [5]Tumlin JA, Chawla L, Tolwani AJ, Mehta R, Dillon J, Finkel KW, Dasilva JR, Astor BC, Yevzlin AS, Humes HD: The effect of the selective cytopheretic device on acute kidney injury outcomes in the intensive care unit: a multicenter pilot study. Semin Dial 2012. doi: 10.1111/sdi.12032
• [6]Yohannes S, Chawla LS: Evolving practices in the management of acute kidney injury in the ICU (Intensive Care Unit). Clin Nephrol 2009, 71:602-607.
• [7]Uchino S, Bellomo R, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, Gibney N, Tolwani A, Doig GS, Oudemans van Straaten H, Ronco C, Kellum JA, Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) Investigators: External validation of severity scoring systems for acute renal failure using a multinational database. Crit Care Med 2005, 33:1961-1967.
• [8]Demirjian S, Chertow GM, Zhang JH, O'Connor TZ, Vitale J, Paganini EP, Palevsky PM, VA/NIH Acute Renal Failure Trial Network: Model to predict mortality in critically ill adults with acute kidney injury. Clin J Am Soc Nephrol 2011, 6:2114-2120.
• [9]Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu H, Morgera S, Schetz M, Tan I, Bouman C, Macedo E, Gibney N, Tolwani A, Ronco C, Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) Investigators: Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA 2005, 294:813-818.
• [10]Ostermann M, Chang RW: Correlation between parameters at initiation of renal replacement therapy and outcome in patients with acute kidney injury. Crit Care 2009, 13:R175. BioMed Central Full Text
• [11]Cappi SB, Sakr Y, Vincent JL: Daily evaluation of organ function during renal replacement therapy in intensive care unit patients with acute renal failure. J Crit Care 2006, 21:179-183.
• [12]Rocha E, Soares M, Valente C, Nogueira L, Bonomo H, Godinho M, Ismael M, Valenca RV, Machado JE, Maccariello E: Outcomes of critically ill patients with acute kidney injury and end-stage renal disease requiring renal replacement therapy: a case-control study. Nephrol Dial Transplant 2009, 24:1925-1930.
• [13]Clermont G, Acker CG, Angus DC, Sirio CA, Pinsky MR, Johnson JP: Renal failure in the ICU: comparison of the impact of acute renal failure and end-stage renal disease on ICU outcomes. Kidney Int 2002, 62:986-996.
• [14]Levey AS, Coresh J, Greene T, Stevens LA, Zhang YL, Hendriksen S, Kusek JW, Van Lente F, Chronic Kidney Disease Epidemiology Collaboration: Using standardized serum creatinine values in the modification of diet in renal disease study equation for estimating glomerular filtration rate. Ann Intern Med 2006, 145:247-254.
• [15]Charlson ME, Pompei P, Ales KL, MacKenzie CR: A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987, 40:373-383.
• [16]Delannoy B, Floccard B, Thiolliere F, Kaaki M, Badet M, Rosselli S, Ber CE, Saez A, Flandreau G, Guerin C: Six-month outcome in acute kidney injury requiring renal replacement therapy in the ICU: a multicentre prospective study. Intensive Care Med 2009, 35:1907-1915.
• [17]Silvester W, Bellomo R, Cole L: Epidemiology, management, and outcome of severe acute renal failure of critical illness in Australia. Crit Care Med 2001, 29:1910-1915.
• [18]Gines A, Escorsell A, Gines P, Salo J, Jimenez W, Inglada L, Navasa M, Claria J, Rimola A, Arroyo V: Incidence, predictive factors, and prognosis of the hepatorenal syndrome in cirrhosis with ascites. Gastroenterology 1993, 105:229-236.
• [19]Brar H, Olivier J, Lebrun C, Gabbard W, Fulop T, Schmidt D: Predictors of mortality in a cohort of intensive care unit patients with acute renal failure receiving continuous renal replacement therapy. Am J Med Sci 2008, 335:342-347.
• [20]Bagshaw SM, Laupland KB, Doig CJ, Mortis G, Fick GH, Mucenski M, Godinez-Luna T, Svenson LW, Rosenal T: Prognosis for long-term survival and renal recovery in critically ill patients with severe acute renal failure: a population-based study. Crit Care 2005, 9:R700-709. BioMed Central Full Text
• [21]Liu KD, Thompson BT, Ancukiewicz M, Steingrub JS, Douglas IS, Matthay MA, Wright P, Peterson MW, Rock P, Hyzy RC, Anzueto A, Truwit JD, National Institutes of Health National Heart and Blood Institute Acute Respiratory Distress Syndrome Network: Acute kidney injury in patients with acute lung injury: impact of fluid accumulation on classification of acute kidney injury and associated outcomes. Crit Care Med 2011, 39:2665-2671.
• [22]Arulkumaran N, Annear NM, Singer M: Patients with end-stage renal disease admitted to the intensive care unit: systematic review. Br J Anaesth 2012, 110:13-20.
• [23]Laupland KB, Kirkpatrick AW, Kortbeek JB, Zuege DJ: Long-term mortality outcome associated with prolonged admission to the ICU. Chest 2006, 129:954-959.
• [24]Meynaar IA, Van Den Boogaard M, Tangkau PL, Dawson L, Sleeswijk Visser S, Bakker J: Long-term survival after ICU treatment. Minerva Anestesiol 2012, 78:1324-1332.
• [25]Davidson TA, Rubenfeld GD, Caldwell ES, Hudson LD, Steinberg KP: The effect of acute respiratory distress syndrome on long-term survival. Am J Respir Crit Care Med 1999, 160:1838-1842.
• [26]Bajwa EK, Malhotra CK, Thompson BT, Christiani DC, Gong MN: Statin therapy as prevention against development of acute respiratory distress syndrome: an observational study. Crit Care Med 2012, 40:1470-1477.
• [27]Sasse KC, Nauenberg E, Long A, Anton B, Tucker HJ, Hu TW: Long-term survival after intensive care unit admission with sepsis. Crit Care Med 1995, 23:1040-1047.
• [28]Wright JC, Plenderleith L, Ridley SA: Long-term survival following intensive care: subgroup analysis and comparison with the general population. Anaesthesia 2003, 58:637-642.
• [29]Niskanen M, Kari A, Halonen P: Five-year survival after intensive care--comparison of 12,180 patients with the general population. Finnish ICU Study Group. Crit Care Med 1996, 24:1962-1967.
• [30]Fertmann J, Wolf H, Kuchenhoff H, Hofner B, Jauch KW, Hartl WH: Prognostic factors in critically ill surgical patients requiring continuous renal replacement therapy. J Nephrol 2008, 21:909-918.
• [31]Lin YF, Ko WJ, Chu TS, Chen YS, Wu VC, Chen YM, Wu MS, Chen YW, Tsai CW, Shiao CC, Li WY, Hu FC, Tsai PR, Tsai TJ, Wu KD, NSARF Study Group: The 90-day mortality and the subsequent renal recovery in critically ill surgical patients requiring acute renal replacement therapy. Am J Surg 2009, 198:325-332.
• [32]Bagshaw SM, Mortis G, Doig CJ, Godinez-Luna T, Fick GH, Laupland KB: One-year mortality in critically ill patients by severity of kidney dysfunction: a population-based assessment. Am J Kidney Dis 2006, 48:402-409.
• [33]Sood MM, Miller L, Komenda P, Reslerova M, Bueti J, Santhianathan C, Roberts D, Mojica J, Rigatto C: Long-term outcomes of end-stage renal disease patients admitted to the ICU. Nephrol Dial Transplant 2011, 26:2965-2970.
• [34]Chapman RJ, Templeton M, Ashworth S, Broomhead R, McLean A, Brett SJ: Long-term survival of chronic dialysis patients following survival from an episode of multiple-organ failure. Crit Care 2009, 13:R65. BioMed Central Full Text
• [35]Heung M, Wolfgram DF, Kommareddi M, Hu Y, Song PX, Ojo AO: Fluid overload at initiation of renal replacement therapy is associated with lack of renal recovery in patients with acute kidney injury. Nephrol Dial Transplant 2012, 27:956-961.
• [36]Bouchard J, Soroko SB, Chertow GM, Himmelfarb J, Ikizler TA, Paganini EP, Mehta RL, Program to Improve Care in Acute Renal Disease (PICARD) Study Group: Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int 2009, 76:422-427.
• [37]Butcher BW, Liu KD: Fluid overload in AKI: epiphenomenon or putative effect on mortality? Curr Opin Crit Care 2012, 18:593-598.