Continuous renal replacement therapy versus intermittent hemodialysis in intensive care patients: impact on mortality and renal recovery.
OBJECTIVE
The best renal replacement therapy (RRT) modality remains controversial. We compared mortality and short- and long-term renal recovery between patients treated with continuous RRT and intermittent hemodialysis.


METHODS
Patients of the prospective observational multicenter cohort database OUTCOMEREA™ were included if they underwent at least one RRT session between 2004 and 2014. Differences in patients' baseline and daily characteristics between treatment groups were taken into account by using a marginal structural Cox model, allowing one to substantially reduce the bias resulting from confounding factors in observational longitudinal data analysis. The composite primary endpoint was 30-day mortality and dialysis dependency.


RESULTS
Among 1360 included patients with RRT, 544 (40.0 %) and 816 (60.0 %) were initially treated by continuous RRT and intermittent hemodialysis, respectively. At day 30, 39.6 % patients were dead. Among survivors, 23.8 % still required RRT. There was no difference between groups for the primary endpoint in global population (HR 1.00, 95 % CI 0.77-1.29; p = 0.97). In patients with higher weight gain at RRT initiation, mortality and dialysis dependency were significantly lower with continuous RRT (HR 0.54, 95 % CI 0.29-0.99; p = 0.05). Conversely, this technique appeared to be deleterious in patients without shock (HR 2.24, 95 % CI 1.24-4.04; p = 0.01). Six-month mortality and persistent renal dysfunction were not influenced by the RRT modality in patients with dialysis dependence at ICU discharge.


CONCLUSIONS
Continuous RRT did not appear to improve 30-day and 6-month patient outcomes. It seems beneficial for patients with fluid overload, but might be deleterious in the absence of hemodynamic failure.
UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, 75018, Paris, France.|Medical Intensive Care Unit, Grenoble University Hospital, Grenoble 1 University, U823, La Tronche, France.|Nephrology, Grenoble University Hospital, La Tronche, France.
Anne-Sophie
http://orcid.org/0000-0003-1570-2251
AS
Truche
Medical Intensive Care Unit, Saint Etienne University Hospital, Saint-Etienne, France.|Jacques Lisfranc Medicine University, Jean Monnet University, Saint-Etienne, France.
Michael
M
Darmon
UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, 75018, Paris, France.|Grenoble Alpes University, U823, Rond-point de La Chantourne, 38700, La Tronche, France.
Sébastien
S
Bailly
UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, 75018, Paris, France.|Intensive Care Unit, AP-HP, Avicenne Hospital, Paris, France.|Medicine University, Paris 13 University, Bobigny, France.
Christophe
C
Clec'h
UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, 75018, Paris, France.|AP-HP, Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University, 75018, Paris, France.
Claire
C
Dupuis
Intensive Care Unit, Saint Joseph Hospital Network, Paris, France.|Sorbonne Cite, Medicine University, Paris Descartes University, Paris, France.
Benoit
B
Misset
Medical Intensive Care Unit, AP-HP, Saint Louis Hospital, Paris, France.|Medicine University, Paris 5 University, Paris, France.
Elie
E
Azoulay
Medical Intensive Care Unit, Grenoble University Hospital, Grenoble 1 University, U823, La Tronche, France.
Carole
C
Schwebel
AP-HP, Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University, 75018, Paris, France.
Lila
L
Bouadma
Medical Surgical ICU, Centre Hospitalier de Cayenne, Guyane, France.
Hatem
H
Kallel
Physiology Department, Cochin University Hospital, Assistance Publique Des Hôpitaux de Paris (AP-HP), Paris Descartes University, Sorbonne Cite, Paris, France.
Christophe
C
Adrie
AP-HP, Antoine Béclère University Hospital, Medical-surgical Intensive Care Unit, Clamart, France.
Anne-Sylvie
AS
Dumenil
Medical Intensive Care Unit, Lyon University Hospital, Lyon, France.
Laurent
L
Argaud
Surgical ICU, Edouard Herriot University Hospital, Lyon, France.
Guillaume
G
Marcotte
Critical Care Medicine Unit Dourdan Hospital, Dourdan, France.
Samir
S
Jamali
Nephrology, Grenoble University Hospital, La Tronche, France.
Philippe
P
Zaoui
Medical Intensive Care Unit, André Mignot Hospital, Versailles, France.
Virginie
V
Laurent
Intensive Care Unit, Gonesse Hospital, Gonesse, France.
Dany
D
Goldgran-Toledano
AP-HP, Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University, 75018, Paris, France.
Romain
R
Sonneville
Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France.
Bertrand
B
Souweine
UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, 75018, Paris, France. Jean-francois.timsit@bch.aphp.fr.|AP-HP, Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University, 75018, Paris, France. Jean-francois.timsit@bch.aphp.fr.|Université Paris Diderot/Hôpital Bichat, Réanimation Medicale et des maladies infectieuses, 46 rue Henri Huchard, Paris, 75018, France. Jean-francois.timsit@bch.aphp.fr.
Jean-Francois
JF
Timsit
D058186:Acute Kidney Injury / Q000401:mortality* / Q000628:therapy*; D000368:Aged; D016009:Chi-Square Distribution; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D011446:Prospective Studies; D006435:Renal Dialysis / Q000009:adverse effects / Q000401:mortality*; D017582:Renal Replacement Therapy / Q000401:mortality*; D016896:Treatment Outcome
Acute kidney injury; Intensive care unit; Marginal structural model; Renal replacement therapy