Anne-Sophie Truche1,2,3, Michael Darmon4,5, Sébastien Bailly1,6, Christophe Clec'h1,7,8, Claire Dupuis1,9, Benoit Misset10,11, Elie Azoulay12,13, Carole Schwebel2, Lila Bouadma9, Hatem Kallel14, Christophe Adrie15, Anne-Sylvie Dumenil16, Laurent Argaud17, Guillaume Marcotte18, Samir Jamali19, Philippe Zaoui3, Virginie Laurent20, Dany Goldgran-Toledano21, Romain Sonneville9, Bertrand Souweine22, Jean-Francois Timsit23,24,25. 1. UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, 75018, Paris, France. 2. Medical Intensive Care Unit, Grenoble University Hospital, Grenoble 1 University, U823, La Tronche, France. 3. Nephrology, Grenoble University Hospital, La Tronche, France. 4. Medical Intensive Care Unit, Saint Etienne University Hospital, Saint-Etienne, France. 5. Jacques Lisfranc Medicine University, Jean Monnet University, Saint-Etienne, France. 6. Grenoble Alpes University, U823, Rond-point de La Chantourne, 38700, La Tronche, France. 7. Intensive Care Unit, AP-HP, Avicenne Hospital, Paris, France. 8. Medicine University, Paris 13 University, Bobigny, France. 9. AP-HP, Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University, 75018, Paris, France. 10. Intensive Care Unit, Saint Joseph Hospital Network, Paris, France. 11. Sorbonne Cite, Medicine University, Paris Descartes University, Paris, France. 12. Medical Intensive Care Unit, AP-HP, Saint Louis Hospital, Paris, France. 13. Medicine University, Paris 5 University, Paris, France. 14. Medical Surgical ICU, Centre Hospitalier de Cayenne, Guyane, France. 15. Physiology Department, Cochin University Hospital, Assistance Publique Des Hôpitaux de Paris (AP-HP), Paris Descartes University, Sorbonne Cite, Paris, France. 16. AP-HP, Antoine Béclère University Hospital, Medical-surgical Intensive Care Unit, Clamart, France. 17. Medical Intensive Care Unit, Lyon University Hospital, Lyon, France. 18. Surgical ICU, Edouard Herriot University Hospital, Lyon, France. 19. Critical Care Medicine Unit Dourdan Hospital, Dourdan, France. 20. Medical Intensive Care Unit, André Mignot Hospital, Versailles, France. 21. Intensive Care Unit, Gonesse Hospital, Gonesse, France. 22. Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France. 23. UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, 75018, Paris, France. Jean-francois.timsit@bch.aphp.fr. 24. AP-HP, Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University, 75018, Paris, France. Jean-francois.timsit@bch.aphp.fr. 25. Université Paris Diderot/Hôpital Bichat, Réanimation Medicale et des maladies infectieuses, 46 rue Henri Huchard, Paris, 75018, France. Jean-francois.timsit@bch.aphp.fr.
Abstract
PURPOSE: The best renal replacement therapy (RRT) modality remains controversial. We compared mortality and short- and long-term renal recovery between patients treated with continuous RRT and intermittent hemodialysis. METHODS: Patients of the prospective observational multicenter cohort database OUTCOMEREA™ were included if they underwent at least one RRT session between 2004 and 2014. Differences in patients' baseline and daily characteristics between treatment groups were taken into account by using a marginal structural Cox model, allowing one to substantially reduce the bias resulting from confounding factors in observational longitudinal data analysis. The composite primary endpoint was 30-day mortality and dialysis dependency. RESULTS: Among 1360 included patients with RRT, 544 (40.0 %) and 816 (60.0 %) were initially treated by continuous RRT and intermittent hemodialysis, respectively. At day 30, 39.6 % patients were dead. Among survivors, 23.8 % still required RRT. There was no difference between groups for the primary endpoint in global population (HR 1.00, 95 % CI 0.77-1.29; p = 0.97). In patients with higher weight gain at RRT initiation, mortality and dialysis dependency were significantly lower with continuous RRT (HR 0.54, 95 % CI 0.29-0.99; p = 0.05). Conversely, this technique appeared to be deleterious in patients without shock (HR 2.24, 95 % CI 1.24-4.04; p = 0.01). Six-month mortality and persistent renal dysfunction were not influenced by the RRT modality in patients with dialysis dependence at ICU discharge. CONCLUSION: Continuous RRT did not appear to improve 30-day and 6-month patient outcomes. It seems beneficial for patients with fluid overload, but might be deleterious in the absence of hemodynamic failure.
PURPOSE: The best renal replacement therapy (RRT) modality remains controversial. We compared mortality and short- and long-term renal recovery between patients treated with continuous RRT and intermittent hemodialysis. METHODS:Patients of the prospective observational multicenter cohort database OUTCOMEREA™ were included if they underwent at least one RRT session between 2004 and 2014. Differences in patients' baseline and daily characteristics between treatment groups were taken into account by using a marginal structural Cox model, allowing one to substantially reduce the bias resulting from confounding factors in observational longitudinal data analysis. The composite primary endpoint was 30-day mortality and dialysis dependency. RESULTS: Among 1360 included patients with RRT, 544 (40.0 %) and 816 (60.0 %) were initially treated by continuous RRT and intermittent hemodialysis, respectively. At day 30, 39.6 % patients were dead. Among survivors, 23.8 % still required RRT. There was no difference between groups for the primary endpoint in global population (HR 1.00, 95 % CI 0.77-1.29; p = 0.97). In patients with higher weight gain at RRT initiation, mortality and dialysis dependency were significantly lower with continuous RRT (HR 0.54, 95 % CI 0.29-0.99; p = 0.05). Conversely, this technique appeared to be deleterious in patients without shock (HR 2.24, 95 % CI 1.24-4.04; p = 0.01). Six-month mortality and persistent renal dysfunction were not influenced by the RRT modality in patients with dialysis dependence at ICU discharge. CONCLUSION: Continuous RRT did not appear to improve 30-day and 6-month patient outcomes. It seems beneficial for patients with fluid overload, but might be deleterious in the absence of hemodynamic failure.
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Authors: Sean M Bagshaw; Michael Darmon; Marlies Ostermann; Fredric O Finkelstein; Ron Wald; Ashita J Tolwani; Stuart L Goldstein; David J Gattas; Shigehiko Uchino; Eric A Hoste; Stephane Gaudry Journal: Intensive Care Med Date: 2017-03-13 Impact factor: 17.440