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VOLUME 20 , ISSUE 1 ( 2016 ) > List of Articles


Impact of dialysis practice patterns on outcomes in acute kidney injury in Intensive Care Unit

Rajeev A. Annigeri, Venkatappa Nandeesh, Ramanathan Karuniya, Sasikumar Rajalakshmi

Keywords : Acute kidney injury, continuous renal replacement therapy hemodialysis, prolonged intermittent renal replacement therapy

Citation Information : Annigeri RA, Nandeesh V, Karuniya R, Rajalakshmi S. Impact of dialysis practice patterns on outcomes in acute kidney injury in Intensive Care Unit. Indian J Crit Care Med 2016; 20 (1):14-20.

DOI: 10.4103/0972-5229.173682

License: CC BY-ND 3.0

Published Online: 01-06-2013

Copyright Statement:  Copyright © 2016; The Author(s).


Aim: Recent advances in dialysis therapy have made an impact on the clinical practice of renal replacement therapy (RRT) in acute kidney injury (AKI) in Intensive Care Unit (ICU). We studied the impact of RRT practice changes on outcomes in AKI in ICU over a period of 8 years. Subjects and Methods: AKI patients requiring RRT in ICU referred to a nephrologist during two different periods (period-1: Between May 2004 and May 2007, n = 69; period-2: Between August 2008 and May 2011, n = 93) were studied. The major changes in the dialysis practice during the period-2, compared to period-1 were introduction of prolonged intermittent RRT (PIRRT), early dialysis for metabolic acidosis, early initiation of RRT for anuria and positive fluid balance and use of bicarbonate-based fluids for continuous RRT (CRRT) instead of lactate buffer. The primary study outcome was 28-day hospital mortality. Results: The mean age was 53.8 ± 16.1 years and 72.6% were male. Introduction of PIRRT resulted in 37% reduction in utilization of CRRT during period-2 (from 85.5% to 53.7%). The overall mortality was high (68%) but was significantly reduced during period-2 compared to period-1 (59% vs. 79.7%, P = 0.006). Metabolic acidosis but not the mode of RRT, was the significant factor which influenced mortality. Conclusions: Adaption of PIRRT resulted in 37% reduction of utilization of CRRT. The mortality rate was significantly reduced during the period of adaption of PIRRT, possibly due to early initiation of RRT in the latter period for indications such as anuria and metabolic acidosis.

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  1. Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu H, Morgera S, et al. Acute renal failure in critically ill patients: A multinational, multicenter study. JAMA 2005;294:813-8.
  2. Joannidis M, Metnitz B, Bauer P, Schusterschitz N, Moreno R, Druml W, et al. Acute kidney injury in critically ill patients classified by AKIN versus RIFLE using the SAPS 3 database. Intensive Care Med 2009;35:1692-702.
  3. Hoste EA, Clermont G, Kersten A, Venkataraman R, Angus DC, De Bacquer D, et al. RIFLE criteria for acute kidney injury are associated with hospital mortality in critically ill patients: A cohort analysis. Crit Care 2006;10:R73.
  4. Reddy NP, Ravi KP, Dhanalakshmi P, Annigeri R, Ramakrishnan N, Venkataraman R. Epidemiology, outcomes and validation of RIFLE and AKIN criteria in acute kidney injury (AKI) in critically ill patients: Indian perspective. Ren Fail 2014;36:831-7.
  5. Chertow GM, Christiansen CL, Cleary PD, Munro C, Lazarus JM. Prognostic stratification in critically ill patients with acute renal failure requiring dialysis. Arch Intern Med 1995;155:1505-11.
  6. Rewa O, Bagshaw SM. Acute kidney injury-epidemiology, outcomes and economics. Nat Rev Nephrol 2014;10:193-207.
  7. 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;62:986-96.
  8. Hsu RK, McCulloch CE, Dudley RA, Lo LJ, Hsu CY. Temporal changes in incidence of dialysis-requiring AKI. J Am Soc Nephrol 2013;24:37-42.
  9. Waikar SS, Curhan GC, Wald R, McCarthy EP, Chertow GM. Declining mortality in patients with acute renal failure, 1988 to 2002. J Am Soc Nephrol 2006;17:1143-50.
  10. Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury. Kidney Int Suppl (2011) 2012;2:1-138.
  11. Kielstein JT, Kretschmer U, Ernst T, Hafer C, Bahr MJ, Haller H, et al. Efficacy and cardiovascular tolerability of extended dialysis in critically ill patients: A randomized controlled study. Am J Kidney Dis 2004;43:342-9.
  12. Fieghen HE, Friedrich JO, Burns KE, Nisenbaum R, Adhikari NK, Hladunewich MA, et al. The hemodynamic tolerability and feasibility of sustained low efficiency dialysis in the management of critically ill patients with acute kidney injury. BMC Nephrol 2010;11:32.
  13. Marshall MR, Ma T, Galler D, Rankin AP, Williams AB. Sustained low-efficiency daily diafiltration (SLEDD-f) for critically ill patients requiring renal replacement therapy: Towards an adequate therapy. Nephrol Dial Transplant 2004;19:877-84.
  14. Holt BG, White JJ, Kuthiala A, Fall P, Szerlip HM. Sustained low-efficiency daily dialysis with hemofiltration for acute kidney injury in the presence of sepsis. Clin Nephrol 2008;69:40-6.
  15. RENAL Study Investigators. Renal replacement therapy for acute kidney injury in Australian and New Zealand intensive care units: A practice survey. Crit Care Resusc 2008;10:225-30.
  16. Pannu N, Klarenbach S, Wiebe N, Manns B, Tonelli M; Alberta Kidney Disease Network. Renal replacement therapy in patients with acute renal failure: A systematic review. JAMA 2008;299:793-805.
  17. Zhang L, Yang J, Eastwood GM, Zhu G, Tanaka A, Bellomo R. Extended daily dialysis versus continuous renal replacement therapy for acute kidney injury: A meta-analysis. Am J Kidney Dis 2015;66:322-30.
  18. Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: A severity of disease classification system. Crit Care Med 1985;13:818-29.
  19. Bellomo R, Ronco C, Kellum JA, Mehta RL, Palevsky P; Acute Dialysis Quality Initiative Workgroup. Acute renal failure - Definition, outcome measures, animal models, fluid therapy and information technology needs: The Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. Crit Care 2004;8:R204-12.
  20. American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: Definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis. Crit Care Med 1992;20:864-74.
  21. Vincent JL, Sakr Y, Sprung CL, Ranieri VM, Reinhart K, Gerlach H, et al. Sepsis in European intensive care units: Results of the SOAP study. Crit Care Med 2006;34:344-53.
  22. Mahajan S, Tiwari S, Bharani R, Bhowmik D, Ravi S, Agarwal SK, et al. Spectrum of acute renal failure and factors predicting its outcome in an intensive care unit in India. Ren Fail 2006;28:119-24.
  23. Sural S, Sharma RK, Singhal MK, Kher V, Gupta A, Arora P, et al. Acute renal failure in an intensive care unit in India - Prognostic factors and outcome. J Nephrol 1999;12:390-4.
  24. Prakash J, Murthy AS, Vohra R, Rajak M, Mathur SK. Acute renal failure in the intensive care unit. J Assoc Physicians India 2006;54:784-8.
  25. Sankarasubbaiyan S, Janardan JD, Kaur P. Outcomes and characteristics of intermittent hemodialysis for acute kidney injury in an intensive care unit. Indian J Nephrol 2013;23:30-3.
  26. Basu G, Chrispal A, Boorugu H, Gopinath KG, Chandy S, Prakash JA, et al. Acute kidney injury in tropical acute febrile illness in a tertiary care centre - RIFLE criteria validation. Nephrol Dial Transplant 2011;26:524-31.
  27. Barenbrock M, Hausberg M, Matzkies F, de la Motte S, Schaefer RM. Effects of bicarbonate- and lactate-buffered replacement fluids on cardiovascular outcome in CVVH patients. Kidney Int 2000;58:1751-7.
  28. National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome (ARDS) Clinical Trials Network, Wiedemann HP, Wheeler AP, Bernard GR, Thompson BT, Hayden D, et al. Comparison of two fluid-management strategies in acute lung injury. N Engl J Med 2006;354:2564-75.
  29. Grams ME, Estrella MM, Coresh J, Brower RG, Liu KD; National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network. Fluid balance, diuretic use, and mortality in acute kidney injury. Clin J Am Soc Nephrol 2011;6:966-73.
  30. Bouchard J, Soroko SB, Chertow GM, Himmelfarb J, Ikizler TA, Paganini EP, et al. Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury. Kidney Int 2009;76:422-7.
  31. Kraut JA, Madias NE. Lactic acidosis. N Engl J Med 2014;371:2309-19.
  32. Berbece AN, Richardson RM. Sustained low-efficiency dialysis in the ICU: Cost, anticoagulation, and solute removal. Kidney Int 2006;70:963-8.
  33. Marshall MR, Creamer JM, Foster M, Ma TM, Mann SL, Fiaccadori E, et al. Mortality rate comparison after switching from continuous to prolonged intermittent renal replacement for acute kidney injury in three intensive care units from different countries. Nephrol Dial Transplant 2011;26:2169-75.
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