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Continuous renal replacement therapy versus intermittent hemodialysis in intensive care patients: impact on mortality and renal recovery

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An Erratum to this article was published on 22 July 2016

Abstract

Purpose

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.

Conclusion

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.

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Acknowledgments

The authors thank Celine Feger, M.D. (EMIBiotech), for her editorial support.

Members of the Outcomerea Study Group

Scientific Committee: Jean-François Timsit (Medical and Infectious Diseases ICU, Bichat-Claude Bernard Hospital, Paris, France; UMR 1137 Inserm–Paris Diderot University IAME, F75018, Paris); Elie Azoulay (Medical ICU, Saint Louis Hospital, Paris, France); Maïté Garrouste-Orgeas (ICU, Saint-Joseph Hospital, Paris, France); Jean-Ralph Zahar (Infection Control Unit, Angers Hospital, Angers, France); Christophe Adrie (ICU, Delafontaine Hospital, Saint Denis, and Physiology, Cochin Hospital, Paris, France); Michael Darmon (Medical ICU, Saint Etienne University Hospital, St Etienne, France); and Christophe Clec’h (ICU, Avicenne Hospital, Bobigny, and UMR 1137 Inserm–Paris Diderot university IAME, F75018, Paris, France).

Biostatistical and Information System Expertise: Jean-Francois Timsit (Medical and Infectious Diseases ICU, Bichat-Claude Bernard Hospital, Paris, France; UMR 1137 Inserm–Paris Diderot university IAME, F75018, Paris); Corinne Alberti (Medical Computer Sciences and Biostatistics Department, Robert Debré Hospital, Paris, France); Adrien Français (Integrated Research Center U823, Grenoble, France); Aurélien Vesin (OUTCOMEREA organization and Integrated Research Center U823, Grenoble, France); Stephane Ruckly (OUTCOMEREA organization and Inserm UMR 1137 IAME, F75018, Paris); Sébastien Bailly (Grenoble University Hospital Inserm UMR 1137 IAME, F75018, Paris) and Christophe Clec’h (ICU, Avicenne Hospital, Bobigny, and Inserm UMR 1137 IAME, F75018, Paris, France); Frederik Lecorre (Supelec, France); Didier Nakache (Conservatoire National des Arts et Métiers, Paris, France); and Aurélien Vannieuwenhuyze (Tourcoing, France).

Investigators of the OUTCOMEREA Database: Christophe Adrie (ICU, Delafontaine Hospital, Saint Denis, and Physiology, Cochin Hospital, Paris, France); Bernard Allaouchiche (ICU, Pierre Benite Hospital, Lyon, France); Laurent Argaud (Medical ICU, Hospices Civils de Lyon, Lyon, France); Claire Ara-Somohano (Medical ICU, University Hospital, Grenoble, France); Elie Azoulay (Medical ICU, Saint Louis Hospital, Paris, France); Francois Barbier (medical-surgical ICU, Orleans, France), Jean-Pierre Bedos (ICU, Versailles Hospital, Versailles, France); Julien Bohé (ICU, Hôpital Pierre Benite, Lyon France), Lila Bouadma (ICU, Bichat Hospital, Paris, France); Christine Cheval (ICU, Hyeres Hospital, Hyeres, France); Christophe Clec’h (ICU, Avicenne Hospital, Bobigny, France); Michael Darmon (ICU, Saint Etienne Hospital, Saint Etienne, France); Anne-Sylvie Dumenil (Antoine Béclère Hospital, Clamart, France); Claire Dupuis (Bichat hospital and UMR 1137 Inserm–Paris Diderot University IAME, F75018, Paris, France), Marc Gainier hôpital la Timone, Marseille, France), Akim Haouache (Surgical ICU, H Mondor Hospital, Creteil, France); Samir Jamali (ICU, Dourdan, Dourdan Hospital, Dourdan, France); Hatem Khallel (ICU, Cayenne General Hospital, Cayenne, France); Alexandre Lautrette (ICU, G Montpied Hospital, Clermont-Ferrand, France); Guillaume Marcotte (Surgical ICU, Hospices Civils de Lyon, Lyon, France); Eric Le Miere (ICU, Louis Mourier Hospital, Colombes, France); Maxime Lugosi (Medical ICU, University Hospital Grenoble, Grenoble, France); Bruno Mourvillier (ICU, Bichat Hospital, Paris, France); Benoît Misset (ICU, Saint-Joseph Hospital, Paris, France); Delphine Moreau (ICU, Saint-Louis Hospital, Paris, France); Bruno Mourvillier (ICU, Bichat Hospital, Paris, France); Laurent Papazian (Hopital Nord, Marseille, France), Benjamin Planquette (pulmonology ICU, George Pompidou Hospital, Versailles, France); Bertrand Souweine (ICU, G Montpied Hospital, Clermont-Ferrand, France); Carole Schwebel (ICU, A Michallon Hospital, Grenoble, France); Gilles Troché (ICU, Antoine Béclère Hospital, Clamart, France); Marie Thuong (ICU, Delafontaine Hospital, Saint Denis, France); Guillaume Thierry (ICU, Saint-Louis Hospital, Paris, France); Dany Toledano (ICU, Gonesse Hospital, Gonesse, France); and Eric Vantalon (SICU, Saint-Joseph Hospital, Paris, France).

Study Monitors: Julien Fournier, Caroline Tournegros, Stéphanie Bagur, Mireille Adda, Vanessa Vindrieux, Loic Ferrand, Nadira Kaddour, Boris Berthe, Samir Bekkhouche, Kaouttar Mellouk, Sylvie Conrozier, Igor Theodose, Veronique Deiler, and Sophie Letrou.

Author information

Authors and Affiliations

  1. UMR 1137, IAME Team 5, DeSCID: Decision Sciences in Infectious Diseases, Control and Care, Sorbonne Paris Cité, Inserm/Paris Diderot University, 75018, Paris, France

    Anne-Sophie Truche, Sébastien Bailly, Christophe Clec’h, Claire Dupuis & Jean-Francois Timsit

  2. Medical Intensive Care Unit, Grenoble University Hospital, Grenoble 1 University, U823, La Tronche, France

    Anne-Sophie Truche & Carole Schwebel

  3. Nephrology, Grenoble University Hospital, La Tronche, France

    Anne-Sophie Truche & Philippe Zaoui

  4. Medical Intensive Care Unit, Saint Etienne University Hospital, Saint-Etienne, France

    Michael Darmon

  5. Jacques Lisfranc Medicine University, Jean Monnet University, Saint-Etienne, France

    Michael Darmon

  6. Grenoble Alpes University, U823, Rond-point de La Chantourne, 38700, La Tronche, France

    Sébastien Bailly

  7. Intensive Care Unit, AP-HP, Avicenne Hospital, Paris, France

    Christophe Clec’h

  8. Medicine University, Paris 13 University, Bobigny, France

    Christophe Clec’h

  9. AP-HP, Bichat Hospital, Medical and Infectious Diseases Intensive Care Unit, Paris Diderot University, 75018, Paris, France

    Claire Dupuis, Lila Bouadma, Romain Sonneville & Jean-Francois Timsit

  10. Intensive Care Unit, Saint Joseph Hospital Network, Paris, France

    Benoit Misset

  11. Sorbonne Cite, Medicine University, Paris Descartes University, Paris, France

    Benoit Misset

  12. Medical Intensive Care Unit, AP-HP, Saint Louis Hospital, Paris, France

    Elie Azoulay

  13. Medicine University, Paris 5 University, Paris, France

    Elie Azoulay

  14. Medical Surgical ICU, Centre Hospitalier de Cayenne, Guyane, France

    Hatem Kallel

  15. Physiology Department, Cochin University Hospital, Assistance Publique Des Hôpitaux de Paris (AP-HP), Paris Descartes University, Sorbonne Cite, Paris, France

    Christophe Adrie

  16. AP-HP, Antoine Béclère University Hospital, Medical-surgical Intensive Care Unit, Clamart, France

    Anne-Sylvie Dumenil

  17. Medical Intensive Care Unit, Lyon University Hospital, Lyon, France

    Laurent Argaud

  18. Surgical ICU, Edouard Herriot University Hospital, Lyon, France

    Guillaume Marcotte

  19. Critical Care Medicine Unit Dourdan Hospital, Dourdan, France

    Samir Jamali

  20. Medical Intensive Care Unit, André Mignot Hospital, Versailles, France

    Virginie Laurent

  21. Intensive Care Unit, Gonesse Hospital, Gonesse, France

    Dany Goldgran-Toledano

  22. Medical Intensive Care Unit, Gabriel Montpied University Hospital, Clermont-Ferrand, France

    Bertrand Souweine

  23. Université Paris Diderot/Hôpital Bichat, Réanimation Medicale et des maladies infectieuses, 46 rue Henri Huchard, Paris, 75018, France

    Jean-Francois Timsit

Authors
  1. Anne-Sophie Truche
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  2. Michael Darmon
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  3. Sébastien Bailly
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  4. Christophe Clec’h
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  5. Claire Dupuis
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  6. Benoit Misset
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  7. Elie Azoulay
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  8. Carole Schwebel
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  9. Lila Bouadma
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  10. Hatem Kallel
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  11. Christophe Adrie
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  12. Anne-Sylvie Dumenil
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  13. Laurent Argaud
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  14. Guillaume Marcotte
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  15. Samir Jamali
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  16. Philippe Zaoui
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  17. Virginie Laurent
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  18. Dany Goldgran-Toledano
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  19. Romain Sonneville
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  20. Bertrand Souweine
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  21. Jean-Francois Timsit
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Consortia

OUTCOMEREA Study Group

Corresponding author

Correspondence to Jean-Francois Timsit.

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Funding

The study was entirely funded by the OUTCOMEREA research network. AST received an educational grant from the French Kidney Foundation under the aegis of the French Medical Research Foundation; code DEA2014FDR/FRM04_FdR-SdN-SFD_FRM_TRUCHE.

Conflicts of interest

The authors declare that they have no conflict of interest.

Additional information

Take-home message: Optimal renal replacement therapy (RRT) technique in the ICU remains controversial, in patients with shock or fluid overload. Cohort studies suggested increased risk of persistent acute kidney injury or dialysis dependency with intermittent hemodialysis. In a MSM Cox model in a cohort of 1360 patients adjusted on daily patients’ characteristics, we found that RRT modality did not influenced neither 30-day mortality nor renal outcome. In subgroups, continuous RRT benefits patients with hemodynamic instability and is deleterious in patients with hemodynamic instability.

This article was presented at the 2016 congress of the French-Language Society of Intensive Care.

The members of the OUTCOMEREA Study Group are listed at the end of this article and in the electronic supplementary material (file ESM 2).

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Truche, AS., Darmon, M., Bailly, S. et al. Continuous renal replacement therapy versus intermittent hemodialysis in intensive care patients: impact on mortality and renal recovery. Intensive Care Med 42, 1408–1417 (2016). https://doi.org/10.1007/s00134-016-4404-6

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