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High-Intensity Dialysis for Acute Kidney Injury Equal to Low-Intensity Dialysis in Treating Intensive Care Patients: Presented at Renal Week 2009

By Kristina Rebelo

SAN DIEGO -- November 3, 2009 -- Treatment with higher-intensity continuous renal replacement therapy (CRRT) did not reduce mortality for patients in the intensive care unit (ICU) with acute kidney injury (AKI), according to trial results released here at the American Society of Nephrology (ASN) Renal Week 2009. In fact, higher-intensity CRRT showed no better efficacy than lower-intensity CRRT.

CRRT is a traditional mode of renal replacement therapy for haemodynamically unstable, fluid-overloaded patients, and also patients with sepsis and septic shock, in the management of acute renal failure, especially in the ICU setting. The optimum intensity of CRRT, however, remains unclear. This multicentre, randomised trial compared the effect of 2 levels of intensity of CRRT on the 90-day mortality in this patient population.

"Findings from previous smaller studies suggested that higher intensity CRRT saved lives," explained lead investigator Alan Cass, MBBS, PhD, The George Institute's Renal and Metabolic Division and Poche Indigenous Health Centre, University of Sydney, Sydney, Australia, speaking here at a late-breaking abstract session on October 30. Dr. Cass and colleagues randomly assigned critically ill patients with AKI (n = 1,508) to CRRT; the primary outcome measure was death at 90 days after randomisation.

The patients were assigned to CRRT as postdilution continuous venovenous haemodiafiltration (CVVHDF), with an effluent flow rate of 40 mL/kg/hour for the higher-intensity group (n = 747) and 25 mL/kg/hour for the lower-intensity group (n = 761).

The study reported results for 721 subjects from the higher-intensity group and 744 subjects from the lower-intensity group. Both groups had similar baseline characteristics and received the CVVHDF treatment for 5.9 and 6.3 days respectively (P = .35).

There were 322 (44.7%) fatal outcomes in the higher-intensity group and 332 (44.7%) deaths in the lower-intensity group at 90 days post randomisation (odds ratio [OR] 1.00; 95% confidence interval [CI], 0.81-1.23; P = .99).

No difference in significance was found between the 2 groups for all secondary and tertiary outcomes.

At 90 days, 6.8% of survivors in the higher-intensity group and 4.4% of survivors in the lower-intensity group were still receiving renal replacement therapy (OR 1.59; 95% CI, 0.86-2.93; P = .14). Hypophosphataemia, however, was more common in the higher-intensity group (54% vs 65%, P < .001).

"This study, while not consistent with the smaller studies, is consistent with the findings of another recent large trial," Dr. Cass concluded. "It found no benefit with the higher-intensity dialysis over standard, lower dialysis treatment. There was no benefit seen in terms of reduction in deaths or length of time in the hospital, nor was there any difference in the need for ongoing and costly dialysis support."

[Presentation title: Intensity of Renal Replacement Therapy in Critically Ill Patients: The Randomized Evaluation of Normal Versus Augmented Level Renal Replacement Therapy (RENAL) Study. Abstract LB-006]

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