No Real Differences Noted In Kidney Failure Treatments
May 24, 2017
According to a recent article published in The Journal of the
American Medical Association, different treatments for acute
kidney failure lead to nearly the same mortality rate and other similar
clinical outcomes. The meta-analysis was performed by Neesh Pannu of
the University of Alberta, Edmonton, Canada and colleagues.
The researchers focused on treatments for acute kidney failure such as
intermittent hemodialysis and continuous kidney replacement therapy
(CRRT). Hemodialysis is a method for removing waste products such as
potassium, urea, and free water from the blood when the kidneys are in
renal failure. CRRT is a technique that allows slow dialysis over 24
hours, just like the kidney.
Acute renal (kidney) failure (ARF) is becoming more frequent, has high
costs, and leads to quite negative outcomes. Patients with ARF have
higher risk of death, stay in the hospital longer, and require chronic
dialysis. Currently, there are several options for treating ARF that
will temporarily or permanently fix the kidney's inability to filter
body fluids. These include intermittent, continuous, and
extended-duration hemodialysis and hemofiltration (CRRT), and
combinations of these.
Pannu and colleagues remark that, "Despite advances in dialysis
technology, many questions remain about how best to provide renal
replacement to patients with ARF."
The researchers reviewed and evaluated current evidence optimal
management of dialysis for patients with ARF. The article search
focused on studies that examined dialytic support in adults with ARF
and that reported the incidence of outcomes such as death, length of
hospital stay, need for repeated dialysis, or development abnormally
low blood pressure (hypotension). Thirty randomized controlled trials
(RCTs) and 8 prospective cohort studies were included in the study from
173 retrieved articles.
After analyzing the 38 studies, the researchers determined that no
conclusions could be drawn about the best indications for or timing of
renal replacement. It was demonstrated that the treatments CRRT and
intermittent hemodialysis did not have any clinically relevant
difference in risk of death or for the need for frequent dialysis
treatment in survivors. The studies also lacked any evidence that CRRT
or intermittent hemodialysis was more cost efficient or better at
reducing the risk of chronic dialysis dependence in ARF patients.
The researchers comment on the suggested treatment strategy for
patients with severe ARF: "The decision to initiate renal replacement
therapy (RRT) in patients with severe ARF requires consideration of
multiple factors, including assessment of intravascular volume,
electrolyte and acid-base status, uremia [retention in the bloodstream
of waste products normally excreted in the urine], nutritional
requirements, urine output, hemodynamic status, and the evolving
clinical course of each patient. Potential advantages of earlier RRT
initiation must be set against the hypothetical risks of
treatment-induced renal injury, bleeding due to anticoagulation, and
mechanical and infectious complications associated with central venous
access."
"Given the significantly higher cost of CRRT, intermittent hemodialysis
may be preferable for patients with ARF who require RRT. In otherwise
stable patients, alternate-day dialysis treatments of 4 or more hours
using blood flows of 250 mL/min or greater are usually sufficient in
patients with or without concomitant critical illness. More frequent
hemodialysis may be required in highly catabolic [a destructive
metabolic process] patients or to achieve treatment targets for fluid,
electrolyte, or acid-base management, although data identifying how
such targets should be set are limited. Despite the lack of data
supporting its superiority and its higher cost, some clinicians may
prefer to use CRRT in critically ill patients with ARF and severe
hemodynamic instability. If CRRT is used, the target dose should be 35
mL/kg per hour [3 L/h in a 154 lb. person]," conclude the authors.
Renal Replacement Therapy in Patients With Acute Renal Failure
Neesh Pannu, Scott Klarenbach, Natasha Wiebe, Braden Manns, and
Marcello Tonelli
JAMA. (2008). Vol. 299 No. 7: pp. 793-805
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: Peter M Crosta