Nephrology Critical Care

Ronco C, Ricci Z, De Backer D, et al. Renal replacement therapy in acute kidney injury: controversy and consensus. Crit Care 2015; 19: 146. A review of strategies for RRT in the ICU, including modalities, adverse effects, and approaches for specific clinical situations.

PMID: 25887923

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Brochard L, Abroug F, Brenner M, et al. for the ATS/ERS/ESICM/SCCM/SRLF Ad Hoc Committee on Acute Renal Failure. Prevention and management of acute renal failure in the ICU patient: an international consensus conference in intensive care medicine. Am J Respir Crit Care Med 2010;181:1128-55. Seeks to answer clinical questions regarding the identification, prevention, and management of acute kidney insufficiency in the intensive care setting, including a discussion of contrast-induced nephropathy.

PMID: 20460549

Vinsonneau C, Camus C, Combes A, et al. Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome. Lancet 2006 ; 368 :379-85. Like previous RCTs addressing this issue, this multicenter study of 360 ICU patients found no advantage to continuous venovenous dialysis in terms of 60-day survival. A limitation of the study is that the delivered dialysis dose may have been suboptimal for both arms.

PMID: 16876666

Gaudry S, Hajage D, Schortgen F, et al. Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med. 2016 ;375:122-33. A randomized trial of early RRT [KDIGO 3: serum creatinine more than 4 mg/dl, greater than 3 times baseline, anuria > 12 hours, or oliguria (<0.3 ml/kg/h or below 500 ml/day) for more than 24 hours] vs late RRT (specified lab changes, or anuria/oliguria lasting > 72 hours). They found no difference in the primary outcome of 60 day mortality. Nearly 50% of late group avoided HD, had fewer line infections, and experienced an earlier return of renal function than the early group. The RRT modality was chosen at the discretion of providers.

PMID: 27181456

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Semler MW, Self WH, Wanderer JP et al.  Balanced crystalloids versus saline in critically ill adults. N Engl J Med. 2018; 378:829-839. A cluster-randomized, multiple-crossover, single-center trial of nearly 16,000 patients compared the effect of saline (0.9% sodium chloride) vs balanced crystalloids (lactated ringer's solution or Plasma-Lyte A) on a composite endpoint of death from any cause, new renal-replacement therapy, and persistent renal dysfunction. The composite endpoint was reached in 14.3% in the balanced-crystalloids group vs. 15.4% in the saline group (p = 0.04).  There was a trend toward a small improvement in mortality in the balanced crystalloid group (2.5 vs 2.9%).

PMID: 29485925

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