Intensity of renal replacement therapy in acute kidney injury: perspective from within the Acute Renal Failure Trial Network Study

Paul M Palevsky,John A Kellum,Theresa Z O'Connor,Jane Zhang,Susan T Crowley,Glenn M Chertow

doi:10.1186/cc7901

Abstract

Determination of the optimal dose of renal replacement therapy in critically ill patients with acute kidney injury has been controversial. Questions have recently been raised regarding the design and execution of the US Department of Veterans Affairs/National Institutes of Health Acute Renal Failure Trial Network (ATN) Study, which demonstrated no improvement in 60-day all-cause mortality with more intensive management of renal replacement therapy. In the present article we present our rationale for these aspects of the design and conduct of the study, including our use of both intermittent and continuous modalities of renal support, our approach to initiation of study therapy and the volume management during study therapy. In addition, the article presents data on hypotension during therapy and recovery of kidney function in the perspective of other studies of renal support in acute kidney injury. Finally, we address the implications of the ATN Study results for clinical practice from the perspective of the study investigators.

Highlights

The optimal intensity of renal replacement therapy (RRT) in acute kidney injury (AKI) remains controversial [1,2,3,4]
We recently published the results of the US Department of Veterans Affairs/National Institutes of Health Acute Renal Failure Trial Network (ATN) Study, which examined the effect of two strategies for the management of RRT on outcomes in critically ill patients with AKI [5]
We designed the US Department of Veterans Affairs/National Institutes of Health ATN Study to test the hypothesis that more intensive RRT in critically ill patients with AKI is associated with improved outcomes

Summary

Introduction

The optimal intensity of renal replacement therapy (RRT) in acute kidney injury (AKI) remains controversial [1,2,3,4]. While demonstrating that the rates of dialysis-associated hypotension in the ATN Study were not unusually high, these data suggest that improved strategies are required to minimize hemodynamic instability during both IHD and CRRT. Some authors have even questioned the reliability of our reported data with regard to the delivered dose of therapy, suggesting inconsistencies between the reported mean daily effluent volume during continuous therapy and the values they calculated from the mean daily duration of treatment and the mean values for dialysate, replacement fluid and net ultrafiltration rates [6] This apparent inconsistency is the result of a repeated mathematical error: the product of mean values does not equal the mean of individual products.

Conclusions

Findings

Palevsky PM