Intermittent versus continuous renal replacement therapy for acute renal failure in adults.
BACKGROUND
Renal replacement therapy (RRT) for acute renal failure (ARF) can be applied intermittently (IRRT) or continuously (CRRT). It has been suggested that CRRT has several advantages over IRRT including better haemodynamic stability, lower mortality and higher renal recovery rates.


OBJECTIVE
To compare CRRT with IRRT to establish if any of these techniques is superior to each other in patients with ARF.


METHODS
We searched MEDLINE, EMBASE, Cochrane Central Register of Controlled Trials (CENTRAL). Authors of included studies were contacted, reference lists of identified studies and relevant narrative reviews were screened. Search date: October 2006.


METHODS
RCTs comparing CRRT with IRRT in adult patients with ARF and reporting prespecified outcomes of interest were included. Studies assessing CAPD were excluded.


METHODS
Two authors assessed trial quality and extracted data. Statistical analyses were performed using the random effects model and the results expressed as relative risk (RR) for dichotomous outcomes or mean difference (WMD) for continuous data with 95% confidence intervals (CI).


RESULTS
We identified 15 studies (1550 patients). CRRT did not differ from IRRT with respect to in-hospital mortality (RR 1.01, 95% CI 0.92 to 1.12), ICU mortality (RR 1.06, 95% CI 0.90 to 1.26), number of surviving patients not requiring RRT (RR 0.99, 95% CI 0.92 to 1.07), haemodynamic instability (RR 0.48, 95% CI 0.10 to 2.28) or hypotension (RR 0.92, 95% CI 0.72 to 1.16) and need for escalation of pressor therapy (RR 0.53, 95% CI 0.26 to 1.08). Patients on CRRT were likely to have significantly higher mean arterial pressure (MAP) (WMD 5.35, 95% CI 1.41 to 9.29) and higher risk of clotting dialysis filters (RR, 95% CI 8.50 CI 1.14 to 63.33).


CONCLUSIONS
In patients who are haemodynamically stable, the RRT modality does not appear to influence important patient outcomes, and therefore the preference for CRRT over IRRT in such patients does not appear justified in the light of available evidence. CRRT was shown to achieve better haemodynamic parameters such as MAP. Future research should focus on factors such as the dose of dialysis and evaluation of newer promising hybrid technologies such as SLED. Triallists should follow the recommendations regarding clinical endpoints assessment in RCTs in ARF made by the Working Group of the Acute Dialysis Quality Initiative Working Group.
Rabindranath
K
K
Churchill Hospital, Renal Unit, Oxford, UK, OX3 7LJ. ksrabi@yahoo.co.uk
Adams
J
J
Macleod
A M
AM
Muirhead
N
N
D058186:Acute Kidney Injury / Q000628:therapy*; D000328:Adult; D017583:Hemodiafiltration / Q000379:methods; D006801:Humans; D016032:Randomized Controlled Trials as Topic; D006435:Renal Dialysis / Q000379:methods*; D017582:Renal Replacement Therapy / Q000379:methods