Stéphane Gaudry1,2, David Hajage3,4,5, Frédérique Schortgen6, Laurent Martin-Lefevre7, Charles Verney1, Bertrand Pons8,9, Eric Boulet10, Alexandre Boyer11, Guillaume Chevrel12, Nicolas Lerolle13, Dorothée Carpentier14, Nicolas de Prost15,16, Alexandre Lautrette17, Anne Bretagnol18, Julien Mayaux19, Saad Nseir20,21, Bruno Megarbane22, Marina Thirion23, Jean-Marie Forel24, Julien Maizel25, Hodane Yonis26, Philippe Markowicz27, Guillaume Thiery8,9, Florence Tubach3,5,28, Jean-Damien Ricard1,29,30, Didier Dreyfuss1,29,30. 1. 1 Service de Réanimation Médico-Chirurgicale, Hôpital Louis Mourier, Assistance Publique-Hôpitaux de Paris (AP-HP), Colombes, France. 2. 2 Unité Mixte de Recherche (UMR) S1155, Remodeling and Repair of Renal Tissue, Hôpital Tenon, French National Institute of Health and Medical Research (INSERM), Paris, France. 3. 3 Epidémiologie Clinique et Évaluation Économique Appliquées aux Populations Vulnérables (ECEVE), U1123, Centre d'Investigation Clinique 1421, INSERM, Paris, France. 4. 4 Université Paris Diderot, Sorbonne Paris Cité, ECEVE, UMRS 1123, Paris, France. 5. 5 Département de Biostatistiques, Santé Publique, et Information Médicale, Hôpital Pitié-Salpêtrière, AP-HP, Paris, France. 6. 6 Service de Réanimation Polyvalente Adulte, Centre Hospitalier Inter-communal, Créteil, France. 7. 7 Réanimation Médico-Chirurgicale, Centre Hospitalier Général, La Roche-sur-Yon, France. 8. 8 Service de Réanimation, Centre Hospitalier Universitaire (CHU) de Pointe à Pitre-Abymes, Pointe à Pitre-Abymes, France. 9. 9 CHU de la Guadeloupe, Pointe-à-Pitre, France. 10. 10 Réanimation Polyvalente, Centre Hospitalier René Dubos, Pontoise, France. 11. 11 Réanimation Médicale, CHU Bordeaux, Hôpital Pellegrin, Bordeaux, France. 12. 12 Service de Réanimation, Centre Hospitalier Sud Francilien, Corbeil Essonne, France. 13. 13 Département de Réanimation Médicale et Médecine Hyperbare, CHU Angers, Université d'Angers, Angers, France. 14. 14 Réanimation Médicale, CHU Rouen, Rouen, France. 15. 15 Service de Réanimation Médicale, Hôpitaux Universitaires Henri Mondor, Département Hospitalo-Universitaire Ageing Thorax-Vessels-Blood, AP-HP, Créteil, France. 16. 16 Cardiovascular and Respiratory Manifestations of Acute Lung Injury and Sepsis (CARMAS) Research Group and Université Paris-Est Créteil Val de Marne, Créteil, France. 17. 17 Réanimation Médicale, Hôpital Gabriel Montpied, CHU de Clermont-Ferrand, Clermont-Ferrand, France. 18. 18 Réanimation Médico-Chirurgicale, Hôpital de La Source, Centre Hospitalier Régional d'Orléans, BP 6709, Orléans, France. 19. 19 Service de Pneumologie et Réanimation Médicale, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris France. 20. 20 Centre de Réanimation, CHU de Lille, Lille, France. 21. 21 Faculté de Médecine, Université de Lille, Lille, France. 22. 22 Réanimation Médicale et Toxicologique, Hôpital Lariboisière, Université Paris-Diderot, INSERM U1144, Paris, France. 23. 23 Réanimation Polyvalente, CH Victor Dupouy, Argenteuil, France. 24. 24 Service de Réanimation des Détresses Respiratoires Aiguës et Infections Sévères, Hôpital Nord Marseille, Marseille, France. 25. 25 Service de Réanimation Médicale CHU de Picardie, INSERM U1088, Amiens, France. 26. 26 Réanimation Médicale, Hôpital de la Croix Rousse, Lyon, France. 27. 27 Réanimation, Centre Hospitalier Cholet, Cholet, France. 28. 28 Université Pierre et Marie Curie, Sorbonne Universités, Paris, France. 29. 29 Université Paris Diderot, Sorbonne Paris Cité, Infection, Antimicrobials, Modelling, Evolution (IAME), UMRS 1137, Paris, France; and. 30. 30 INSERM, IAME, U1137, Paris, France.
Abstract
RATIONALE: The optimal strategy for initiation of renal replacement therapy (RRT) in patients with severe acute kidney injury in the context of septic shock and acute respiratory distress syndrome (ARDS) is unknown. OBJECTIVES: To examine the effect of an early compared with a delayed RRT initiation strategy on 60-day mortality according to baseline sepsis status, ARDS status, and severity. METHODS: Post hoc analysis of the AKIKI (Artificial Kidney Initiation in Kidney Injury) trial. MEASUREMENTS AND MAIN RESULTS: Subgroups were defined according to baseline characteristics: sepsis status (Sepsis-3 definition), ARDS status (Berlin definition), Simplified Acute Physiology Score 3 (SAPS 3), and Sepsis-related Organ Failure Assessment (SOFA). Of 619 patients, 348 (56%) had septic shock and 207 (33%) had ARDS. We found no significant influence of the baseline sepsis status (P = 0.28), baseline ARDS status (P = 0.94), and baseline severity scores (P = 0.77 and P = 0.46 for SAPS 3 and SOFA, respectively) on the comparison of 60-day mortality according to RRT initiation strategy. A delayed RRT initiation strategy allowed 45% of patients with septic shock and 46% of patients with ARDS to escape RRT. Urine output was higher in the delayed group. Renal function recovery occurred earlier with the delayed RRT strategy in patients with septic shock or ARDS (P < 0.001 and P = 0.003, respectively). Time to successful extubation in patients with ARDS was not affected by RRT strategy (P = 0.43). CONCLUSIONS: Early RRT initiation strategy was not associated with any improvement of 60-day mortality in patients with severe acute kidney injury and septic shock or ARDS. Unnecessary and potentially risky procedures might often be avoided in these fragile populations. Clinical trial registered with www.clinicaltrials.gov (NCT 01932190).
RCT Entities:
RATIONALE: The optimal strategy for initiation of renal replacement therapy (RRT) in patients with severe acute kidney injury in the context of septic shock and acute respiratory distress syndrome (ARDS) is unknown. OBJECTIVES: To examine the effect of an early compared with a delayed RRT initiation strategy on 60-day mortality according to baseline sepsis status, ARDS status, and severity. METHODS: Post hoc analysis of the AKIKI (Artificial Kidney Initiation in Kidney Injury) trial. MEASUREMENTS AND MAIN RESULTS: Subgroups were defined according to baseline characteristics: sepsis status (Sepsis-3 definition), ARDS status (Berlin definition), Simplified Acute Physiology Score 3 (SAPS 3), and Sepsis-related Organ Failure Assessment (SOFA). Of 619 patients, 348 (56%) had septic shock and 207 (33%) had ARDS. We found no significant influence of the baseline sepsis status (P = 0.28), baseline ARDS status (P = 0.94), and baseline severity scores (P = 0.77 and P = 0.46 for SAPS 3 and SOFA, respectively) on the comparison of 60-day mortality according to RRT initiation strategy. A delayed RRT initiation strategy allowed 45% of patients with septic shock and 46% of patients with ARDS to escape RRT. Urine output was higher in the delayed group. Renal function recovery occurred earlier with the delayed RRT strategy in patients with septic shock or ARDS (P < 0.001 and P = 0.003, respectively). Time to successful extubation in patients with ARDS was not affected by RRT strategy (P = 0.43). CONCLUSIONS: Early RRT initiation strategy was not associated with any improvement of 60-day mortality in patients with severe acute kidney injury and septic shock or ARDS. Unnecessary and potentially risky procedures might often be avoided in these fragile populations. Clinical trial registered with www.clinicaltrials.gov (NCT 01932190).
Authors: Sadudee Peerapornratana; Carlos L Manrique-Caballero; Hernando Gómez; John A Kellum Journal: Kidney Int Date: 2019-06-07 Impact factor: 10.612
Authors: Fabrice Uhel; Hessel Peters-Sengers; Fahimeh Falahi; Brendon P Scicluna; Lonneke A van Vught; Marc J Bonten; Olaf L Cremer; Marcus J Schultz; Tom van der Poll Journal: Intensive Care Med Date: 2020-06-08 Impact factor: 17.440