Goal-directed therapy in patients with early acute kidney injury: a multicenter randomized controlled trial

Cristina Prata Amendola,João Manoel Silva-Jr,Taisa Carvalho,Luciana Coelho Sanches,Ulysses Vasconcelos De Andrade E Silva,Rosana Almeida,Emmanuel Burdmann,Emerson Lima,Fabiana Ferreira Barbosa,Renata Souza Ferreira,Maria José C Carmona,Luiz Marcelo Sá Malbouisson,Fernando A M Nogueira,José Otavio Costa Auler-Júnior,Suzana Margareth Lobo

doi:10.6061/clinics/2018/e327

Abstract

OBJECTIVES:Acute kidney injury is associated with many conditions, and no interventions to improve the outcomes of established acute kidney injury have been developed. We performed this study to determine whether goal-directed therapy conducted during the early stages of acute kidney injury could change the course of the disease.METHODS:This was a multicenter prospective randomized controlled study. Patients with early acute kidney injury in the critical care unit were randomly allocated to a standard care (control) group or a goal-directed therapy group with 8h of intensive treatment to maximize oxygen delivery, and all patients were evaluated during a period of 72h. ClinicalTrials.gov: NCT02414906.RESULTS:A total of 143 patients were eligible for the study, and 99 patients were randomized. Central venous oxygen saturation was significantly increased and the serum lactate level significantly was decreased from baseline levels in the goal-directed therapy group (p=0.001) compared to the control group (p=0.572). No significant differences in the change in serum creatinine level (p=0.96), persistence of acute kidney injury beyond 72h (p=0.064) or the need for renal replacement therapy (p=0.82) were observed between the two groups. In-hospital mortality was significantly lower in the goal-directed therapy group than in the control group (33% vs. 51%; RR: 0.61, 95% CI: 0.37-1.00, p=0.048, number needed to treat=5).CONCLUSIONS:Goal-directed therapy for patients in the early stages of acute kidney injury did not change the disease course.

Highlights

Acute kidney injury (AKI) is currently defined by abrupt and small changes in serum creatinine (SCr) levels, which are associated with adverse short-term and long-term outcomes
A total of 143 patients were eligible during the enrollment period from April 2010 to December 2013, of which 44 were excluded due to the following: lack of informed consent (n=13), monitoring tools not available (n=9), AKI longer than 12h (n=7), cardiac arrhythmia (n=7), recent myocardial infarction (n=3), nephrectomy (n=2), intensive care unit (ICU) length of stay (LOS) longer than 10 days (n=1) and survival expectancy less than 3 months (n=2)
The main findings of our study are that goal-directed therapy (GDT) prevented tissue hypoxia and decreased mortality relative to standard therapy but did not change the course of AKI

Summary

Introduction

Acute kidney injury (AKI) is currently defined by abrupt and small changes in serum creatinine (SCr) levels, which are associated with adverse short-term and long-term outcomes. Even transient episodes of oliguria appear to be associated with long-term hazards [1, 2]. The estimated overall incidence of AKI in the intensive care unit (ICU) ranges from 11% to 100%, and its mortality may be greater than 68% in septic patients [3, 4]. More than 50% of the patients at risk for AKI develop kidney injury or failure [5].

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Conclusion