A- ARF quoted without specification
F- 08: Hemodynamic instability during dialysis
Dialysis Complications in Acute Kidney Injury Patients Treated With
Prolonged Intermittent Renal Replacement Therapy Sessions Lasting 10
Versus 6 Hours: Results of a Randomized Clinical Trial
Bianca Ballarin Albino, André Luis Balbi, Juliana Maria Gera Abrão and Daniela Ponce
Journal : Artificial Organs
Year : 2015 / Month : May
Volume : 39
Pages 423–431
Keywords:
Acute kidney injury
Extended dialysis
Dialysis complications
ABSTRACT
Prolonged intermittent renal replacement therapy (PIRRT) has emerged as an alternative to
continuous renal replacement therapy in the management of acute kidney injury (AKI) patients. This
trial aimed to compare the dialysis complications occurring during different durations of PIRRT
sessions in critically ill AKI patients. We included patients older than 18 years with AKI associated
with sepsis admitted to the intensive care unit and using noradrenaline doses ranging from 0.3 to
0.7 µg/kg/min. Patients were divided into two groups randomly: in G1, 6-h sessions were performed,
and in G2, 10-h sessions were performed. Seventy-five patients were treated with 195 PIRRT
sessions for 18 consecutive months. The prevalence of hypotension, filter clotting, hypokalemia, and
hypophosphatemia was 82.6, 25.3, 20, and 10.6%, respectively. G1 was composed of 38 patients
treated with 100 sessions, whereas G2 consisted of 37 patients treated with 95 sessions. G1 and G2
were similar in male predominance (65.7 vs. 75.6%, P = 0.34), age (63.6 ± 14 vs. 59.9 ± 15.5 years,
P = 0.28) and Sequential Organ Failure Assessment score (SOFA; 13.1 ± 2.4 vs. 14.2 ± 3.0, P = 0.2).
There was no significant difference between the two groups in hypotension (81.5 vs. 83.7%, P = 0.8),
filter clotting (23.6 vs. 27%, P = 0.73), hypokalemia (13.1 vs. 8.1%, P = 0.71), and hypophosphatemia
(18.4 vs. 21.6%, P = 0.72). However, the group treated with sessions of 10 h were refractory to
clinical measures for hypotension, and dialysis sessions were interrupted more often (9.5 vs. 30.1%,
P = 0.03). Metabolic control and fluid balance were similar between G1 and G2 (blood urea nitrogen
[BUN]: 81 ± 30 vs. 73 ± 33 mg/dL, P = 1.0; delivered Kt/V: 1.09 ± 0.24 vs. 1.26 ± 0.26, P = 0.09; actual
ultrafiltration: 1731 ± 818 vs. 2332 ± 947 mL, P = 0.13) and fluid balance (–731 ± 125 vs.
−652 ± 141 mL, respectively) . In conclusion, intradialysis hypotension was common in AKI patients
treated with PIRRT. There was no difference in the prevalence of dialysis complications in patients
undergoing different durations of PIRRT.
COMMENTS
There is no consensus on the best dialysis method; intermittent hemodialysis (IHD) and continuous
renal replacement therapies (CRRT) to treat Acute Kidney Insufficiency (AKI). Among them, a hybrid
therapy called prolonged intermittent renal replacement therapy (PIRRT) has emerged as an
alternative to CRRT in the management of hemodynamically unstable patients with AKI.
This prospective clinical trial was designed to evaluate and compare the intra- and postdialysis
complications in critically ill AKI patients undergoing PIRRT.
The PIRRT session lasted 6 or 10 h according to randomization and carried out 6 days a week. A
double lumen catheter was used for central venous access. An HD machine with volumetric control
(Fresenius 4008F [Fresenius Kabi, Bad Homburg, Germany] or Gambro K200 [Gambro Americas,
Lakewood, CO, USA]) and cellulose acetate dialyzers (CA 150 or 170 with surface areas of 1.2 and
1.5 m2, respectively were used for sessions of 6 and 10 h, respectively). Blood flow was 200 mL/min
and dialysate flow was 300 mL/min. Anticoagulation was achieved with unfractionated heparin
(usually a 1000 U bolus followed by 500 U/h) or saline flushes of 100 mL, given every 30 min if
anticoagulation was contraindicated.
203 patients were treated by dialysis: 101 by PIRRT (49.6%); 45 by conventional IHD (22%); 14 by
CRRT (6.9%); and 43 by high-volume peritoneal dialysis (PD; 21.1%). The criteria for chosen
modality are not well indicated.
Hypotension was frequent and present in 62 patients (82.6%) and 116 PIRRT sessions (58.9%),
despite the measures to avoid hypotension, such as the low temperature of dialysate (35 to 35.5°C),
high sodium (142–145 mmol/L), and actual UF rate not exceeding 500 mL/h. There was no difference
between the two groups treated with PIRRT sessions of 6 versus 10 h in relation to hypotension
episodes (63 vs. 55.8%, P = 0.21).
Filter clotting occurred in 19 patients (25.3%) and in 29 sessions (14.9%), similar to the data reported
in the literature. There was no difference in filter clotting between the groups treated with 6 versus
10 h of PIRRT sessions (11 vs. 18.9%, P = 0.72).
Metabolic control and fluid status were similar in the groups treated with 6-h versus 10-h PIRRT
sessions. The blood and dialysate flows were the same between the two groups (200 and
300 mL/min, respectively), and cellulose acetate dialyzers were different (CA 150 for lasting 6 h and
170 for lasting 10 h, with surface areas of 1.2 and 1.5 m2, respectively).
These results showed that intra- and postdialysis complications were similar between the groups
treated with prolonged intermittent renal replacement therapy lasting 6 versus 10 h, and that the
group treated with sessions of 10 h were more refractory to clinical measures for hypotension and
dialysis sessions were interrupted more often, with no benefit in treating acute kidney injury patients
with more prolonged sessions.
Pr. Jacques CHANARD
Professor of Nephrology