Continuous renal replacement therapy versus intermittent hemodialysis as first modality for renal replacement therapy in severe acute kidney injury: a secondary analysis of AKIKI and IDEAL-ICU studies
2022
Gaudry, Stéphane | Grolleau, François | Barbar, Saber | Martin-Lefevre, Laurent | Pons, Bertrand | Boulet, Éric | Boyer, Alexandre | Chevrel, Guillaume | Montini, Florent | Bohe, Julien | Badie, Julio | Rigaud, Jean-Philippe | Vinsonneau, Christophe | Porcher, Raphaël | Quenot, Jean-Pierre | Dreyfuss, Didier | CoRaKiD - Maladies rénales fréquentes et rares : des mécanismes moléculaires à la médecine personnalisée (CoRaKID) ; Institut National de la Santé et de la Recherche Médicale (INSERM)-Sorbonne Université (SU) | Centre for Research in Epidemiology and Statistics | Centre de Recherche Épidémiologie et Statistiques (CRESS (U1153 / UMR_A 1125)) ; Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité)-Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE) | Methods of therapeutic evaluation of chronic diseases | Méthodes de l’évaluation thérapeutique des maladies chroniques (METHODS [CRESS - U1153 / UMR_A 1125]) ; Centre for Research in Epidemiology and Statistics | Centre de Recherche Épidémiologie et Statistiques (CRESS (U1153 / UMR_A 1125)) ; Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité)-Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Université Paris Cité (UPCité)-Institut National de Recherche pour l’Agriculture, l’Alimentation et l’Environnement (INRAE) | Centre d'épidémiologie Clinique [Hôtel-Dieu] ; Assistance publique - Hôpitaux de Paris (AP-HP) (AP-HP)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Hôpital Hôtel Dieu | Hôpital Universitaire Carémeau [Nîmes] (CHU Nîmes) ; Centre Hospitalier Universitaire de Nîmes (CHU Nîmes) | Centre Hospitalier Départemental - Hôpital de La Roche-sur-Yon (CHD Vendée) | CHU Pointe-à-Pitre / Abymes [Guadeloupe] | Groupe hospitalier Carnelle Portes de l'Oise | Centre Hospitalier Universitaire de Bordeaux (CHU Bordeaux) | Centre Hospitalier Sud Francilien | Centre Hospitalier Henri Duffaut (Avignon) | Centre Hospitalier Lyon Sud [CHU - HCL] (CHLS) ; Hospices Civils de Lyon (HCL) | Hôpital Nord Franche-Comté [Hôpital de Trévenans] (HNFC) | Centre hospitalier de Dieppe | Centre Hospitalier de Béthune Beuvry (CH Béthune Beuvry) | Equipe LIPNESS (LNC - U1231) (LIPNESS) ; Lipides - Nutrition - Cancer [Dijon - U1231] (LNC) ; Université de Bourgogne (UB)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Institut Agro Dijon ; Institut national d'enseignement supérieur pour l'agriculture, l'alimentation et l'environnement (Institut Agro)-Institut national d'enseignement supérieur pour l'agriculture, l'alimentation et l'environnement (Institut Agro)-Université de Bourgogne (UB)-Institut National de la Santé et de la Recherche Médicale (INSERM)-Institut Agro Dijon ; Institut national d'enseignement supérieur pour l'agriculture, l'alimentation et l'environnement (Institut Agro)-Institut national d'enseignement supérieur pour l'agriculture, l'alimentation et l'environnement (Institut Agro)
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Show more [+] Less [-]English. Background:Intermittent hemodialysis (IHD) and continuous renal replacement therapy (CRRT) are the two main RRT modalities in patients with severe acute kidney injury (AKI). Meta-analyses conducted more than 10 years ago did not show survival difference between these two modalities. As the quality of RRT delivery has improved since then, we aimed to reassess whether the choice of IHD or CRRT as the first modality affects survival of patients with severe AKI.Methods:This is a secondary analysis of two multicenter randomized controlled trials (AKIKI and IDEAL-ICU) that compared an early RRT initiation strategy with a delayed one. We included patients allocated to the early strategy in order to emulate a trial where patients would have been randomized to receive either IHD or CRRT within twelve hours after the documentation of severe AKI. We determined each patient’s modality group as the first RRT modality they received. The primary outcome was 60-day overall survival. We used two propensity score methods to balance the differences in baseline characteristics between groups and the primary analysis relied on inverse probability of treatment weighting.Results:A total of 543 patients were included. Continuous RRT was the first modality in 269 patients and IHD in 274. Patients receiving CRRT had higher cardiovascular and total-SOFA scores. Inverse probability weighting allowed to adequately balance groups on all predefined confounders. The weighted Kaplan–Meier death rate at day 60 was 54·4% in the CRRT group and 46·5% in the IHD group (weighted HR 1·26, 95% CI 1·01–1·60). In a complementary analysis of less severely ill patients (SOFA score: 3–10), receiving IHD was associated with better day 60 survival compared to CRRT (weighted HR 1.82, 95% CI 1·01–3·28; p < 0.01). We found no evidence of a survival difference between the two RRT modalities in more severe patients.Conclusion:Compared to IHD, CRRT as the first modality seemed to convey no benefit in terms of survival or of kidney recovery and might even have been associated with less favorable outcome in patients with lesser severity of disease. A prospective randomized non-inferiority trial should be implemented to solve the persistent conundrum of the optimal RRT technique.
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