Association between diuretics and successful discontinuation of continuous renal replacement therapy in critically ill patients with acute kidney injury

Junseok Jeon,Jung Eun Lee,Kyeongman Jeon,Yoon-Goo Kim,Song In Baeg,Hye Ryoun Jang,Ha Young Oh,Gee Young Suh,Do Hee Kim,Wooseong Huh,Chi Ryang Chung,Dae Joong Kim,Eun Jeong Lee

doi:10.1186/s13054-018-2192-9

Abstract

BackgroundDespite aggressive application of continuous renal replacement therapy (CRRT) in critically ill patients with acute kidney injury (AKI), there is no consensus on diuretic therapy when discontinuation of CRRT is attempted. The effect of diuretics on discontinuation of CRRT in critically ill patients was evaluated.MethodsThis retrospective cohort study enrolled 1176 adult patients who survived for more than 3 days after discontinuing CRRT between 2009 and 2014. Patients were categorized depending on the re-initiation of renal replacement therapy within 3 days after discontinuing CRRT or use of diuretics. Changes in urine output (UO) and renal function after discontinuing CRRT were outcomes. Predictive factors for successful discontinuation of CRRT were also analyzed.ResultsThe CRRT discontinuation group had a shorter duration of CRRT, more frequent use of diuretics after discontinuing CRRT, and greater UO on the day before CRRT discontinuation [day minus 1 (day − 1)]. The diuretics group had greater increases in UO and serum creatinine elevation after discontinuing CRRT. In the CRRT discontinuation group, continuous infusion of furosemide tended to increase UO more effectively. Multivariable regression analysis identified high day − 1 UO and use of diuretics as significant predictors of successful discontinuation of CRRT. Day − 1 UO of 125 mL/day was the cutoff value for predicting successful discontinuation of CRRT in oliguric patients treated with diuretics following CRRT.ConclusionsDay − 1 UO and aggressive diuretic therapy were associated with successful CRRT discontinuation. Diuretic therapy may be helpful when attempting CRRT discontinuation in critically ill patients with AKI, by inducing a favorable fluid balance, especially in oliguric patients.

Highlights

Despite aggressive application of continuous renal replacement therapy (CRRT) in critically ill patients with acute kidney injury (AKI), there is no consensus on diuretic therapy when discontinuation of CRRT is attempted
The CRRT discontinuation group had greater urine output (UO) compared with other groups at 1 day prior to starting CRRT and 1 day prior to stopping CRRT, and had a shorter duration of CRRT compared to other groups (Table 1)
In this study, we demonstrated that starting diuretics at the cessation of CRRT contributes to successful discontinuation of CRRT by reducing volume overload risk in critically ill patients with AKI

Summary

Introduction

Despite aggressive application of continuous renal replacement therapy (CRRT) in critically ill patients with acute kidney injury (AKI), there is no consensus on diuretic therapy when discontinuation of CRRT is attempted. The effect of diuretics on discontinuation of CRRT in critically ill patients was evaluated. Acute kidney injury (AKI) is a major morbidity in critically ill patients and is associated with high mortality [1]. Continuous renal replacement therapy (CRRT) is the preferred treatment option for critically ill patients with AKI requiring RRT due to better hemodynamic tolerance and steadier solute control [7,8,9]. Despite aggressive application of CRRT in critically-ill patients with AKI over the last decade, evidence-based guidelines for optimal timing and adequate methods for CRRT discontinuation are lacking [10]. Several studies have reported lower sequential organ failure assessment scores, fewer prior CRRT cycles, younger age, and higher urine output (UO) after discontinuing CRRT as predictors of renal recovery after AKI requiring CRRT [11,12,13]

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