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Impact of timing of renal replacement therapy initiation on outcome of septic acute kidney injury

Yu-Hsiang Chou1, Tao-Min Huang2, Vin-Cent Wu1, Cheng-Yi Wang3, Chih-Chung Shiao4, Chun-Fu Lai1, Hung-Bin Tsai5, Chia-Ter Chao1, Guang-Huar Young6, Wei-Jei Wang7, Tze-Wah Kao1, Shuei-Liong Lin1, Yin-Yi Han5, Anne Chou5, Tzu-Hsin Lin6, Ya-Wen Yang8, Yung-Ming Chen1, Pi-Ru Tsai4, Yu-Feng Lin8, Jenq-Wen Huang1, Wen-Chih Chiang1, Nai-Kuan Chou6, Wen-Je Ko6*, Kwan-Dun Wu1, Tun-Jun Tsai1 and the NSARF Study Group9

Author Affiliations

1 Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei 100, Taiwan

2 Division of Nephrology, Department of Internal Medicine, National Taiwan University Hospital, Yun-Lin branch, 579, Sec. 2, Yunlin Rd., Douliu City, Yunlin County 640, Taiwan

3 Department of Internal Medicine, Cardinal Tien Hospital, 362, Zhongzheng Rd., Xindian City, Taipei County 231, Taiwan

4 Division of Nephrology, Department of Internal Medicine, Saint Mary's Hospital, 160 Chong-Cheng South Road, Lotung 265, I-Lan, Taiwan

5 Department of Internal Medicine, Buddhist Dalin Tzu Chi General Hospital, 2 Minsheng Road, Dalin Township, Chiayi County 622, Taiwan

6 Department of Surgery, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei 100, Taiwan

7 Department of Internal Medicine, Tao-Yuan General Hospital, 6 Sinfu 2nd Road, Sinwu Township, Taoyuan County 327, Taiwan

8 Department of Traumatology, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei 100, Taiwan

9 National Taiwan University Hospital Study Group on Acute Renal Failure, National Taiwan University Hospital, No.7, Chung Shan S. Rd, Taipei 100, Taiwan

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Critical Care 2011, 15:R134  doi:10.1186/cc10252


See related commentary by Lameire et al., http://ccforum.com/content/15/4/171

Published: 6 June 2011

Abstract

Introduction

Sepsis is the leading cause of acute kidney injury (AKI) in critical patients. The optimal timing of initiating renal replacement therapy (RRT) in septic AKI patients remains controversial. The objective of this study is 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 (sRIFLE), on hospital mortality among septic AKI patients.

Methods

Patient with sepsis and AKI requiring RRT in surgical intensive care units were enrolled between January 2002 and October 2009. The patients were divided into early (sRIFLE-0 or -Risk) or late (sRIFLE-Injury or -Failure) initiation of RRT by sRIFLE criteria. Cox proportional hazard ratios for in hospital mortality were determined to assess the impact of timing of RRT.

Results

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). Patients with heart failure, male gender, higher admission creatinine, and operation were more likely to be in the late RRT group. Cox proportional hazard model, after adjustment with propensity score including all patients based on the probability of late RRT, showed early dialysis was not related to hospital mortality. Further model matched patients by 1:1 fashion according to each patient's propensity to late RRT showed no differences in hospital mortality according to head-to-head comparison of demographic data (P > 0.05).

Conclusions

Use of sRIFLE classification as a marker poorly predicted the benefits of early or late RRT in the context of septic AKI. In the future, more physiologically meaningful markers with which to determine the optimal timing of RRT initiation should be identified.