June 1, 2008

Intensity of Renal Support in Critically Ill Patients with Acute Kidney Injury.

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Critical Care
  • Ron Wald

    This is a landmark paper for many reasons. It definitively “breaks the tie” between the 4 prior RCTs that studied the impact of renal replacement therapy (RRT) dose on survival. The study is remarkable for its methodologic rigour: there were no systematic differences between the groups and patients in either arm got the RRT intensity/protocol that was intended. Rather than focusing on a single RRT modality (eg, CRRT), the ability for patients to move between RRT modalities depending on hemodynamic stability is a reflection of clinical practice. A similar study that is examining CVVHDF at 40 vs 25 mL/kg/hr is near completion in Australia/New Zealand and results are expected in early 2009. Unless the results are divergent, the current state of knowledge suggests that CRRT should be administered at 20 mL/kg/hr to most patients with hemodynamic instability and in hemodynamically stable patients, alternate day IHD is adequate.

    ATN is also a major achievement for AKI research as it refutes the oft-repeated assertion that trials involving interventions for AKI are too tough to implement and that large studies involving complex interventions can’t be done. Now that a “gold standard” study has been completed, clinicians should not settle for anything less in the future.

    Now that the issue of RRT dose has been (virtually) settled, there remain several crucial quesitons in the area of renal replacement therapy that demand definitive RCTs. Timing of RRT initiation (and specifically, whether early intervention is helpful) and the relative merit of convective (as compared to diffusive) therapies are chief among the issues that need further exploration.