Abstract
IntroductionAmong critically ill patients with acute kidney injury (AKI) needing continuous renal replacement therapy (CRRT), the effect of convective (via continuous venovenous hemofiltration [CVVH]) versus diffusive (via continuous venovenous hemodialysis [CVVHD]) solute clearance on clinical outcomes is unclear. Our objective was to evaluate the feasibility of comparing these two modes in a randomized trial.MethodsThis was a multicenter open-label parallel-group pilot randomized trial of CVVH versus CVVHD. Using concealed allocation, we randomized critically ill adults with AKI and hemodynamic instability to CVVH or CVVHD, with a prescribed small solute clearance of 35 mL/kg/hour in both arms. The primary outcome was trial feasibility, defined by randomization of >25% of eligible patients, delivery of >75% of the prescribed CRRT dose, and follow-up of >95% of patients to 60 days. A secondary analysis using a mixed-effects model examined the impact of therapy on illness severity, defined by sequential organ failure assessment (SOFA) score, over the first week.ResultsWe randomized 78 patients (mean age 61.5 years; 39% women; 23% with chronic kidney disease; 82% with sepsis). Baseline SOFA scores (mean 15.9, SD 3.2) were similar between groups. We recruited 55% of eligible patients, delivered >80% of the prescribed dose in each arm, and achieved 100% follow-up. SOFA tended to decline more over the first week in CVVH recipients (-0.8, 95% CI -2.1, +0.5) driven by a reduction in vasopressor requirements. Mortality (54% CVVH; 55% CVVHD) and dialysis dependence in survivors (24% CVVH; 19% CVVHD) at 60 days were similar.ConclusionsOur results suggest that a large trial comparing CVVH to CVVHD would be feasible. There is a trend toward improved vasopressor requirements among CVVH-treated patients over the first week of treatment.Trial RegistrationClinicalTrials.gov: NCT00675818
Highlights
Among critically ill patients with acute kidney injury (AKI) needing continuous renal replacement therapy (CRRT), the effect of convective versus diffusive solute clearance on clinical outcomes is unclear
Prior to the start of therapy it was recognized that a patient randomized to continuous venovenous hemodialysis (CVVHD) was inappropriately enrolled as the indication for RRT was toxin removal rather than AKI per se
After adjustment for baseline sequential organ failure assessment (SOFA) score, we found a non-significant decline in SOFA score among participants treated with continuous venovenous hemofiltration (CVVH) compared to CVVHD on the first day (-0.4, 95% confidence intervals (CI) -1.3, 0.6) and second day (-0.4, 95% CI -1.6, 0.8) following randomization
Summary
Among critically ill patients with acute kidney injury (AKI) needing continuous renal replacement therapy (CRRT), the effect of convective (via continuous venovenous hemofiltration [CVVH]) versus diffusive (via continuous venovenous hemodialysis [CVVHD]) solute clearance on clinical outcomes is unclear. When filter characteristics are kept constant, hemofiltration, which more faithfully mimics glomerular filtration, should result in the clearance of larger-sized solutes as compared to hemodialysis [7]. The removal of such solutes, which may include toxic mediators of sepsis and inflammation, provides the theoretical underpinnings for the superiority of hemofiltration as a renal support mode for critically ill patients with AKI
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