Background The optimal intensity of renal-replacement therapyin critically ill patients with acute kidney injury is controversial.
Methods We randomly assigned critically ill patients with acutekidney injury and failure of at least one nonrenal organ orsepsis to receive intensive or less intensive renal-replacementtherapy. The primary end point was death from any cause by day60. In both study groups, hemodynamically stable patients underwentintermittent hemodialysis, and hemodynamically unstable patientsunderwent continuous venovenous hemodiafiltration or sustainedlow-efficiency dialysis. Patients receiving the intensive treatmentstrategy underwent intermittent hemodialysis and sustained low-efficiencydialysis six times per week and continuous venovenous hemodiafiltrationat 35 ml per kilogram of body weight per hour; for patientsreceiving the less-intensive treatment strategy, the correspondingtreatments were provided thrice weekly and at 20 ml per kilogramper hour.
Results Baseline characteristics of the 1124 patients in thetwo groups were similar. The rate of death from any cause byday 60 was 53.6% with intensive therapy and 51.5% with less-intensivetherapy (odds ratio, 1.09; 95% confidence interval, 0.86 to1.40; P=0.47). There was no significant difference between thetwo groups in the duration of renal-replacement therapy or therate of recovery of kidney function or nonrenal organ failure.Hypotension during intermittent dialysis occurred in more patientsrandomly assigned to receive intensive therapy, although thefrequency of hemodialysis sessions complicated by hypotensionwas similar in the two groups.
Conclusions Intensive renal support in critically ill patientswith acute kidney injury did not decrease mortality, improverecovery of kidney function, or reduce the rate of nonrenalorgan failure as compared with less-intensive therapy involvinga defined dose of intermittent hemodialysis three times perweek and continuous renal-replacement therapy at 20 ml per kilogramper hour. (ClinicalTrials.gov number, NCT00076219
[ClinicalTrials.gov]
.)
Source Information
The members of the writing committee (Paul M. Palevsky, M.D., Jane Hongyuan Zhang, Ph.D., Theresa Z. O'Connor, Ph.D., Glenn M. Chertow, M.D., M.P.H., Susan T. Crowley, M.D., Devasmita Choudhury, M.D., Kevin Finkel, M.D., John A. Kellum, M.D., Emil Paganini, M.D., Roland M.H. Schein, M.D., Mark W. Smith, Ph.D., Kathleen M. Swanson, M.S., R.Ph., B. Taylor Thompson, M.D., Anitha Vijayan, M.D., Suzanne Watnick, M.D., Robert A. Star, M.D., and Peter Peduzzi, Ph.D.) of the Veterans Affairs/National Institutes of Health (VA/NIH) Acute Renal Failure Trial Network assume responsibility for the overall content and integrity of the article. This article (10.1056/NEJMoa0802639) was published at www.nejm.org on May 20, 2008. It will appear in the July 3 issue of the Journal.
Address reprint requests to Dr. Palevsky at Rm. 7E123 (111F-U), VA Pittsburgh Healthcare System, University Dr., Pittsburgh, PA 15240, or at palevsky{at}pitt.edu.
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