Blog entry by mohamed buhary
Chou et al (Critical Care 2011, 15:R134; doi:10.1186/cc10252) revisited an important and controversial subject: the timing for renal replacement therapy (RRT) in acute kidney injury in septic patients. The objective of their study was to determine the impact of early or late initiation of RRT, as defined using the simplified RIFLE (risk, injury, failure, loss of kidney function, and end-stage renal failure) classification on hospital mortality among septic AKI patients. For this, patient with sepsis and AKI requiring RRT in surgical intensive care units were enrolled from 01/2002 to 10/October 2009. They found that among the 370 patients, 192 (51.9%) underwent early RRT and 259 (70.0%) died during hospitalization. The mortality rate in early and late RRT groups were 70.8% and 69.7% respectively (P > 0.05). Early dialysis did not relate to hospital mortality by Cox proportional hazard model (P > 0.05). They concluded that the RIFLE classification is not good enough to find patients that could benefit from early or late RRT in the context of septic AKI.
Some authors have advocate the institution of early RRT as a measure to improve prognosis in AKI patients. While this is clear in some presentations, as AKI associated white leptospirosis or AKI after major abdominal surgery, this is not clear in others. In the septic patient, in special with severe sepsis or shock, RRT can harm the patient if the haemodinamic stability is not previously achieved. In particular for the development countries, the timing to start RRT depends on the skills of the local service, the availability of equipment and trained personnel. Before thinking in RRT, be sure that the initial targets for the critical patient were achieved, as hemodynamic stability and adequate oxygen delivery. After that, many patients will improve the renal function without RRT. Some trials in AKI found that early RRT had better prognosis, but without a intention-to-treat design, meaning that they could have included patients that would not need RRT.
The paper is available at: http://ccforum.com/content/pdf/cc10252.pdf.