ABSTRACTS from 16th International COnference on ... - CRRT Online

Comparing RRT Modalities: Does it Matter What You Use if the Job is Done?
Sean Bagshaw MD, MSc, FRCPC
5:00-5:15
Thursday, February 16
Educational Objectives:
1. Describe the azotemic, metabolic and volume homeostasis of available RRT modalities.
2. Describe the mortality associated with RRT modality in critically ill patients with AKI.
3. Describe the epidemiology of renal recovery associated with RRT modality in critically ill patients with AKI.
Content Description:
Acute kidney injury (AKI) commonly afflicts critically ill patients and generally portends an increased morbidity
and mortality. What is more, a majority of patients with severe AKI require, at least provisionally, a period of
extracorporeal RRT. Despite extensive use of RRT in this population, there remains controversy and debate about
whether the initial type of RRT, either conventional IHD or CRRT, can impact survival or recovery of kidney
function. This is important given the resource implications and infrastructure needed for delivery of both types of
RRT in critically ill patients.
Several trials have shown a higher occurrence of hemodynamic instability prompting intervention, and greater
fluid accumulation for those receiving conventional IHD compared with CRRT. Observational data also suggest
achievement of fluid balance goals are more likely to occur with CRRT compared with IHD. On the other hand,
rather than use of conventional IHD or CRRT, newer hybrid modalities such as slow low-efficiency dialysis
(SLED) may prove advantageous in such circumstances. SLED shares the benefits of both CRRT and IRRT and
thus, can enable adequate dose delivery, fewer hemodynamic complications and be greater likelihood of achieving
fluid balance goals. To date, no randomized trials of SLED that incorporate survival or renal recovery as outcomes
have been performed.
Thus, the uncertainty on the ideal selection of initial RRT modality in critically ill patients with AKI for optimizing
outcomes, reducing treatment-related complications and conserve health resources has remains. There is a
wide-spectrum of patients who are critically ill and there clinical course is often not static. Accordingly, the
selection of RRT modality, similar to decisions for when to initiate RRT, is strongly influenced by numerous
patient-specific, clinician-specific and organizational factors. Instead, it is probably that the selection of RRT
modality should center around when to prescribe a particular RRT modality, based on the real-time individual
needs of the critically ill patient.
Suggested Reading:
1. Bagshaw SM, Berthiaume LR, Delaney A, Bellomo R. Continuous versus intermittent renal replacement therapy
for critically ill patients with acute kidney injury: a meta-analysis. Crit Care Med. Feb 2008;36(2):610-617.
2. Bagshaw SM, Gibney N. Renal support in critically ill patients with acute kidney injury. N Engl J Med. Oct
30 2008;359(18):1960-1961.
3. Pannu N, Klarenbach S, Wiebe N, Manns B, Tonelli M. Renal replacement therapy in patients with acute renal
failure: a systematic review. JAMA. Feb 20 2008;299(7):793-805.
4. Rabindranath K, Adams J, Macleod AM, Muirhead N. Intermittent versus continuous renal replacement therapy
for acute renal failure in adults. Cochrane Database Syst Rev. 2007(3):CD003773.
5. Bellomo R, Cass A, Cole L, et al. Intensity of continuous renal-replacement therapy in critically ill patients. N
Engl J Med. Oct 22 2009;361(17):1627-1638.
6. Palevsky PM, Zhang JH, O'Connor TZ, et al. Intensity of renal support in critically ill patients with acute kidney
injury. N Engl J Med. Jul 3 2008;359(1):7-20.
7. Uchino S, Bellomo R, Kellum JA, et al. Patient and kidney survival by dialysis modality in critically ill
patients with acute kidney injury. Int J Artif Organs. Apr 2007;30(4):281-292.
8. Marshall MR, Golper TA, Shaver MJ, Alam MG, Chatoth DK. Sustained low-efficiency dialysis for critically
ill patients requiring renal replacement therapy. Kidney Int. Aug 2001;60(2):777-785.
9. Fieghen HE, Friedrich JO, Burns KE, 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.
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