Timing of Renal Support and Outcome of Septic Shock and Acute Respiratory Distress Syndrome.

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Abstract

RATIONALE

The optimal strategy for initiation of renal replacement therapy (RRT) in patients with severe acute kidney injury in the context of septic shock and acute respiratory distress syndrome (ARDS) is unknown.

OBJECTIVE

To examine the effect of an early compared to a delayed RRT initiation strategy on 60-day mortality according to the baseline sepsis status, ARDS status and severity.

METHODS

Post-hoc analysis of the AKIKI (Artificial-Kidney-Initiation in Kidney-Injury) trial.

MEASUREMENTS AND MAIN RESULTS

Subgroups were defined according to baseline characteristics: sepsis status (Sepsis-3 definition), ARDS status (Berlin definition), SAPS3 and SOFA. Of 619 patients, 348 (56%) had septic shock and 207 (33%) ARDS. We found no significant influence of the baseline sepsis status (p=0.28), baseline ARDS status (p=0.94) and baseline severity scores (p=0.77 and 0.46 respectively) on the comparison of 60 day-mortality according to RRT initiation strategy. A delayed RRT initiation strategy allowed 45 % of septic shock and 46% of ARDS patients to escape RRT. Urine output was higher in the delayed group. Renal function recovery occurred earlier with the delayed RRT strategy in patients with septic shock or ARDS (p<0.001 and p=0.003 respectively). Time to successful extubation in ARDS patients was not affected by RRT strategy (p = 0.43).

CONCLUSION

Early RRT initiation strategy was not associated with any improvement of day-60 mortality in patients with severe acute kidney injury and septic shock or ARDS. Unnecessary and potentially risky procedures might often be avoided in these fragile populations. Clinical trial registration available at www.clinicaltrials.gov, ID NCT01932190.

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