Impact of timing of renal replacement therapy initiation on outcome of septic acute kidney injury

The, Chou Yu-Hsiang, Huang Tao-Min, Wu Vin-Cent, Wang Cheng-Yi, Shiao Chih-Chung, Lai Chun-Fu, Tsai Hung-Bin, Chao Chia-Ter, Young Guang-Huar, Wang Wei-Jei, Kao Tze-Wah, Lin Shuei-Liong, Han Yin-Yi, Chou Anne, Lin Tzu-Hsin, Yang Ya-Wen, Chen Yung-Ming, Tsai Pi-Ru, Lin Yu-Feng, Huang Jenq-Wen, Chiang Wen-Chih, Chou Nai-Kuan, Ko Wen-Je, Wu Kwan-Dun, Tsai Tun-Jun

Description

Sepsis is the leading cause of acute kidney injury (AKI) in critical patients. The optimal timing of initiating renal replacement therapy (RRT) in septic AKI patients remains controversial. The objective of this study is to determine the impact of early or late initiation of RRT, as defined using the simplified RIFLE (risk, injury, failure, loss of kidney function, and end-stage renal failure) classification (sRIFLE), on hospital mortality among septic AKI patients. Methods Patient with sepsis and AKI requiring RRT in surgical intensive care units were enrolled between January 2002 and October 2009. The patients were divided into early (sRIFLE-0 or -Risk) or late (sRIFLE-Injury or -Failure) initiation of RRT by sRIFLE criteria. Cox proportional hazard ratios for in hospital mortality were determined to assess the impact of timing of RRT. Results Among the 370 patients, 192 (51.9%) underwent early RRT and 259 (70.0%) died during hospitalization. The mortality rate in early and late RRT groups were 70.8% and 69.7% respectively ( P > 0.05). Early dialysis did not relate to hospital mortality by Cox proportional hazard model ( P > 0.05). Patients with heart failure, male gender, higher admission creatinine, and operation were more likely to be in the late RRT group. Cox proportional hazard model, after adjustment with propensity score including all patients based on the probability of late RRT, showed early dialysis was not related to hospital mortality. Further model matched patients by 1:1 fashion according to each patient's propensity to late RRT showed no differences in hospital mortality according to head-to-head comparison of demographic data ( P > 0.05). Conclusions Use of sRIFLE classification as a marker poorly predicted the benefits of early or late RRT in the context of septic AKI. In the future, more physiologically meaningful markers with which to determine the optimal timing of RRT initiation should be identified.

Informations

• Publié par: biomed
• Publié le: 01 janvier 2011
• Nombre de lectures: 92
• Langue: English

Extrait

Chouet al.Critical Care2011,15:R134 http://ccforum.com/content/15/3/R134

R E S E A R C HOpen Access Impact of timing of renal replacement therapy initiation on outcome of septic acute kidney injury 1†2†1 34 1 YuHsiang Chou, TaoMin Huang, VinCent Wu , ChengYi Wang , ChihChung Shiao , ChunFu Lai , 5 16 71 15 HungBin Tsai , ChiaTer Chao , GuangHuar Young , WeiJei Wang , TzeWah Kao , ShueiLiong Lin , YinYi Han , 5 68 14 81 Anne Chou , TzuHsin Lin , YaWen Yang , YungMing Chen , PiRu Tsai , YuFeng Lin , JenqWen Huang , 1 66* 11 9 WenChih Chiang , NaiKuan Chou , WenJe Ko, KwanDun Wu , TunJun Tsaiand for the NSARF Study Group

Abstract Introduction:Sepsis is the leading cause of acute kidney injury (AKI) in critical patients. The optimal timing of initiating renal replacement therapy (RRT) in septic AKI patients remains controversial. The objective of this study is to determine the impact of early or late initiation of RRT, as defined using the simplified RIFLE (risk, injury, failure, loss of kidney function, and endstage renal failure) classification (sRIFLE), on hospital mortality among septic AKI patients. Methods:Patient with sepsis and AKI requiring RRT in surgical intensive care units were enrolled between January 2002 and October 2009. The patients were divided into early (sRIFLE0 or Risk) or late (sRIFLEInjury or Failure) initiation of RRT by sRIFLE criteria. Cox proportional hazard ratios for in hospital mortality were determined to assess the impact of timing of RRT. Results:Among the 370 patients, 192 (51.9%) underwent early RRT and 259 (70.0%) died during hospitalization. The mortality rate in early and late RRT groups were 70.8% and 69.7% respectively (P> 0.05). Early dialysis did not relate to hospital mortality by Cox proportional hazard model (P> 0.05). Patients with heart failure, male gender, higher admission creatinine, and operation were more likely to be in the late RRT group. Cox proportional hazard model, after adjustment with propensity score including all patients based on the probability of late RRT, showed early dialysis was not related to hospital mortality. Further model matched patients by 1:1 fashion according to each patient’s propensity to late RRT showed no differences in hospital mortality according to headtohead comparison of demographic data (P> 0.05). Conclusions:Use of sRIFLE classification as a marker poorly predicted the benefits of early or late RRT in the context of septic AKI. In the future, more physiologically meaningful markers with which to determine the optimal timing of RRT initiation should be identified.

Introduction Acute kidney injury (AKI) is a common entity in criti cally ill patients with an incidence of about 30 to 60% [1] as defined by the RIFLE (risk, injury, failure, loss of kidney function, and endstage renal failure) classifica tion and is thought to be an independent risk factor for

* Correspondence: [e-mail] †Contributed equally 6 Department of Surgery, National Taiwan University Hospital, 7 ChungShan South Road, Taipei 100, Taiwan Full list of author information is available at the end of the article

increased morbidity and mortality [24]. Sepsis is the leading cause of AKI, contributing to 30 to 50% of cases of AKI [4,5]. Almost 30% of septic AKI patients need renal replacement therapy (RRT). This rate is much higher than that observed for other causes of AKI [68]. Among critically ill patients, mortality rates of patients with septic AKI are also higher than among patients with nonseptic AKI [9]. Thus, finding better strategies for septic AKI is the key issue for intensivists. The cur rent goal is to improve strategies for the treatment of patients with septic AKI.

© 2011 Chou et al.; licensee BioMed Central Ltd. This is an open access article distributed under the terms of the Creative Commons Attribution License http://creativecommons.org/licenses/by/2.0, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.