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1. Intensity of Continuous Renal-Replacement Therapy in Critically Ill Patients

Author

Bellomo, R, Cass, A, Norton, R, Gallagher, M, Lo, S, Su, S, Cole, L, Finfer, S, McArthur, C, McGuinness, S, Myburgh, J, Scheinkestel, C, Lee, J, Ali, D, Goldsmith, D, Banerjee, A, Bhonagiri, D, Blythe, D, Botha, J, Cade, J, Dobb, G, Eddington, J, Flabouris, A, French, C, Garrett, P, Henderson, S, Ihle, B, Joyce, C, Kalkoff, M, Lipman, J, Milliss, D, Mitchell, I, Morgan, J, Nair, P, Orford, N, Raza, A, Shehabi, Y, Tobin, A, Totaro, R, Turner, A, Wright, C, Little, L, Morrison, A, Regaglia, G, Shukla, R, Baigent, C, Emberson, J, Wheeler, D, Young, D, Billot, L, Bompoint, S, Heritier, S, Lo, SN, Pillai, A, Pandey, S, Ryan, S, Schmidt, M, Starzec, G, Vijayan, B, Ashley, R, Gissane, J, Malchukova, K, Ranse, J, Nand, K, Sara, T, Cheung, W, Fugaccia, E, Lawrence, P, Millis, D, Tan, J, Thankrishnan, G, Wong, H, Harrigan, P, Crowfoot, E, Hardie, M, Micallef, S, Brieva, J, Lintott, M, Seppelt, I, Gresham, R, Nikas, M, Weisbrodt, L, Bass, F, Boyle, M, Campbell, M, Hammond, N, Ankers, S, O'Connor, A, Potter, J, Rajbhandari, D, Dhiacou, V, Jovanovska, A, Munster, F, Breeding, J, Burns, C, Morrison, M, Pfeffercorn, C, Ritchie, A, Buhr, H, Eccleston, M, Parke, R, Bell, J, Newby, L, Mehrtens, J, West, C, Rudder, L, Sutton, J, Groves, N, McDonald, S, Jaspers, J, Harwood, M, Helyar, J, Mackie, B, Boots, R, Bertenshaw, C, Deans, R, Fourie, C, Lassig-Smith, M, Stuart, J, Edwards, J, O'Connor, S, Lewis, K, Rivett, J, Field, T, McAllister, R, Marsden, K, Mathlin, C, Mercer, I, O'Sullivan, K, Edington, J, Boschert, C, Smith, J, Graan, M, Ho, S, Fowler, N, McInness, J, Pratt, N, Elderkin, T, Fraser, M, Kinmonth, A, Barrett, J, Wilson, S, Galt, P, Burton, S, Culhane, C, Ioannidis, R, Roberston, M, Barge, D, Caf, T, Howe, B, Low, P, Holmes, J, Smith, R, Davies, A, Murray, L, Nevill, R, Vallance, S, Varley, S, White, V, Raunow, H, Palermo, A, Boardman, M, Chamberlain, J, Gould, A, McEntaggart, G, Perryman, S, Thomas, L, and In, RENALRTS

Subjects
Male, medicine.medical_specialty, Randomization, Critical Illness, medicine.medical_treatment, Hemodiafiltration, Kaplan-Meier Estimate, law.invention, Randomized controlled trial, law, Internal medicine, medicine, Humans, Prospective Studies, Renal replacement therapy, Prospective cohort study, Aged, business.industry, Acute kidney injury, General Medicine, Odds ratio, Acute Kidney Injury, Middle Aged, medicine.disease, Confidence interval, Surgery, Treatment Outcome, Female, business, Hypophosphatemia
Abstract

Background The optimal intensity of continuous renal-replacement therapy remains unclear. We conducted a multicenter, randomized trial to compare the effect of this therapy, delivered at two different levels of intensity, on 90-day mortality among critically ill patients with acute kidney injury. Methods We randomly assigned critically ill adults with acute kidney injury to continuous renal-replacement therapy in the form of postdilution continuous venovenous hemodiafiltration with an effluent flow of either 40 ml per kilogram of body weight per hour (higher intensity) or 25 ml per kilogram per hour (lower intensity). The primary outcome measure was death within 90 days after randomization. Results Of the 1508 enrolled patients, 747 were randomly assigned to higher-intensity therapy, and 761 to lower-intensity therapy with continuous venovenous hemodiafiltration. Data on primary outcomes were available for 1464 patients (97.1%): 721 in the higher-intensity group and 743 in the lower-intensity group. The two study groups had similar baseline characteristics and received the study treatment for an average of 6.3 and 5.9 days, respectively (P = 0.35). At 90 days after randomization, 322 deaths had occurred in the higher-intensity group and 332 deaths in the lower-intensity group, for a mortality of 44.7% in each group (odds ratio, 1.00; 95% confidence interval [CI], 0.81 to 1.23; P = 0.99). At 90 days, 6.8% of survivors in the higher-intensity group (27 of 399), as compared with 4.4% of survivors in the lower-intensity group (18 of 411), were still receiving renal-replacement therapy (odds ratio, 1.59; 95% CI, 0.86 to 2.92; P = 0.14). Hypophosphatemia was more common in the higher-intensity group than in the lower-intensity group (65% vs. 54%, P Conclusions In critically ill patients with acute kidney injury, treatment with higher-intensity continuous renal-replacement therapy did not reduce mortality at 90 days. (ClinicalTrials.gov number, NCT00221013.)

Published
2016

3. Calorie intake and patient outcomes in severe acute kidney injury: Findings from The Randomized Evaluation of Normal vs. Augmented Level of Replacement Therapy (RENAL) study trial.

Author

Nair P., Kalkoff M., West C., Morgan J., Rudder L., Sutton J., Garrett P., Groves N., McDonald S., Jennifer Palmer a., Joyce C., Harwood M., Helyar J., Mackie B., Lipman J., Boots R., Bertenshaw C., Deans R., Fourie C., Lassig-Smith M., Flabouris A., Edwards J., O'Connor S., Rivett J., Turner A., Field T., Marsden K., Mathlin C., Goldsmith D., Mercer I., O'Sullivan K., Edington J., Boschert C., Smith J., Ihle B., Graan M., Ho S., Botha J., Fowler N., McInness J., Pratt N., Orford N., Elderkin T., Fraser M., Kinmonth A., Wright C., Burton S., Culhane C., Galt P., Rutzou R., Roberston M., Barge D., Caf T., Howe B., Low P., Tobin A., Holmes J., Smith R., Murray L., Nevill R., Vallance S., Varley S., White V., French C., Little L., Raunow H., Blythe D., Palermo A., Dobb G., Boardman M., Chamberlain J., Gould A., McEntaggart G., Perryman S., Thomas L., Bellomo R., Cass A., Cole L., Finfer S., Gallagher M., Lee J., Lo S., McArthur C., McGuinness S., Myburgh J., Norton R., Scheinkestel C., Mitchell I., Ashley R., Gissane J., Malchukova K., Ranse J., Raza A., Nand K., Sara T., Millis D., Tan J., Wong H., Harrigan P., Crowfoot E., Hardie M., Bhonagiri D., Micallef S., Brieva J., Lintott M., Gresham R., Nikas M., Weisbrodt L., Shehabi Y., Bass F., Campbell M., Stockdale V., Ankers S., O'Connor A., Potter J., Totaro R., Rajbhandari D., Dhiacou V., Jovanovska A., Munster F., Davies A., Breeding J., Burns C., Banerjee A., Morrison M., Pfeffercorn C., Ritchie A., Buhr H., Eccleston M., Parke R., Bell J., Newby L., Henderson S., Mehrtens J., Nair P., Kalkoff M., West C., Morgan J., Rudder L., Sutton J., Garrett P., Groves N., McDonald S., Jennifer Palmer a., Joyce C., Harwood M., Helyar J., Mackie B., Lipman J., Boots R., Bertenshaw C., Deans R., Fourie C., Lassig-Smith M., Flabouris A., Edwards J., O'Connor S., Rivett J., Turner A., Field T., Marsden K., Mathlin C., Goldsmith D., Mercer I., O'Sullivan K., Edington J., Boschert C., Smith J., Ihle B., Graan M., Ho S., Botha J., Fowler N., McInness J., Pratt N., Orford N., Elderkin T., Fraser M., Kinmonth A., Wright C., Burton S., Culhane C., Galt P., Rutzou R., Roberston M., Barge D., Caf T., Howe B., Low P., Tobin A., Holmes J., Smith R., Murray L., Nevill R., Vallance S., Varley S., White V., French C., Little L., Raunow H., Blythe D., Palermo A., Dobb G., Boardman M., Chamberlain J., Gould A., McEntaggart G., Perryman S., Thomas L., Bellomo R., Cass A., Cole L., Finfer S., Gallagher M., Lee J., Lo S., McArthur C., McGuinness S., Myburgh J., Norton R., Scheinkestel C., Mitchell I., Ashley R., Gissane J., Malchukova K., Ranse J., Raza A., Nand K., Sara T., Millis D., Tan J., Wong H., Harrigan P., Crowfoot E., Hardie M., Bhonagiri D., Micallef S., Brieva J., Lintott M., Gresham R., Nikas M., Weisbrodt L., Shehabi Y., Bass F., Campbell M., Stockdale V., Ankers S., O'Connor A., Potter J., Totaro R., Rajbhandari D., Dhiacou V., Jovanovska A., Munster F., Davies A., Breeding J., Burns C., Banerjee A., Morrison M., Pfeffercorn C., Ritchie A., Buhr H., Eccleston M., Parke R., Bell J., Newby L., Henderson S., and Mehrtens J.

Abstract

Introduction: Current practice in the delivery of caloric intake (DCI) in patients with severe acute kidney injury (AKI) receiving renal replacement therapy (RRT) is unknown. We aimed to describe calorie administration in patients enrolled in the Randomized Evaluation of Normal vs. Augmented Level of Replacement Therapy (RENAL) study and to assess the association between DCI and clinical outcomes. Method(s): We performed a secondary analysis in 1456 patients from the RENAL trial. We measured the dose and evolution of DCI during treatment and analyzed its association with major clinical outcomes using multivariable logistic regression, Cox proportional hazards models, and time adjusted models. Result(s): Overall, mean DCI during treatment in ICU was low at only 10.9 +/- 9 Kcal/kg/day for non-survivors and 11 +/- 9 Kcal/kg/day for survivors. Among patients with a lower DCI (below the median) 334 of 729 (45.8%) had died at 90-days after randomization compared with 316 of 727 (43.3%) patients with a higher DCI (above the median) (P = 0.34). On multivariable logistic regression analysis, mean DCI carried an odds ratio of 0.95 (95% confidence interval (CI): 0.91-1.00; P = 0.06) per 100 Kcal increase for 90-day mortality. DCI was not associated with significant differences in renal replacement (RRT) free days, mechanical ventilation free days, ICU free days and hospital free days. These findings remained essentially unaltered after time adjusted analysis and Cox proportional hazards modeling. Conclusion(s): In the RENAL study, mean DCI was low. Within the limits of such low caloric intake, greater DCI was not associated with improved clinical outcomes. © 2014 Bellomo et al.; licensee BioMed Central Ltd.

Published
2014

4. Calorie intake and patient outcomes in severe acute kidney injury: Findings from The Randomized Evaluation of Normal vs. Augmented Level of Replacement Therapy (RENAL) study trial

Author

Bellomo, R, Cass, A, Cole, L, Finfer, S, Gallagher, M, Lee, J, Lo, S, McArthur, C, McGuinness, S, Myburgh, J, Norton, R, Scheinkestel, C, Mitchell, I, Ashley, R, Gissane, J, Malchukova, K, Ranse, J, Raza, A, Nand, K, Sara, T, Millis, D, Tan, J, Wong, H, Harrigan, P, Crowfoot, E, Hardie, M, Bhonagiri, D, Micallef, S, Brieva, J, Lintott, M, Gresham, R, Nikas, M, Weisbrodt, L, Shehabi, Y, Bass, F, Campbell, M, Stockdale, V, Ankers, S, O'Connor, A, Potter, J, Totaro, R, Rajbhandari, D, Dhiacou, V, Jovanovska, A, Munster, F, Nair, P, Breeding, J, Burns, C, Banerjee, A, Morrison, M, Pfeffercorn, C, Ritchie, A, Buhr, H, Eccleston, M, Parke, R, Bell, J, Newby, L, Henderson, S, Mehrtens, J, Kalkoff, M, West, C, Morgan, J, Rudder, L, Sutton, J, Garrett, P, Groves, N, McDonald, S, Jennifer Palmer, A, Joyce, C, Harwood, M, Helyar, J, Mackie, B, Lipman, J, Boots, R, Bertenshaw, C, Deans, R, Fourie, C, Lassig-Smith, M, Flabouris, A, Edwards, J, O'Connor, S, Rivett, J, Turner, A, Field, T, Marsden, K, Mathlin, C, Goldsmith, D, Mercer, I, O'Sullivan, K, Edington, J, Boschert, C, Smith, J, Ihle, B, Graan, M, Ho, S, Botha, J, Fowler, N, McInness, J, Pratt, N, Orford, N, Bellomo, R, Cass, A, Cole, L, Finfer, S, Gallagher, M, Lee, J, Lo, S, McArthur, C, McGuinness, S, Myburgh, J, Norton, R, Scheinkestel, C, Mitchell, I, Ashley, R, Gissane, J, Malchukova, K, Ranse, J, Raza, A, Nand, K, Sara, T, Millis, D, Tan, J, Wong, H, Harrigan, P, Crowfoot, E, Hardie, M, Bhonagiri, D, Micallef, S, Brieva, J, Lintott, M, Gresham, R, Nikas, M, Weisbrodt, L, Shehabi, Y, Bass, F, Campbell, M, Stockdale, V, Ankers, S, O'Connor, A, Potter, J, Totaro, R, Rajbhandari, D, Dhiacou, V, Jovanovska, A, Munster, F, Nair, P, Breeding, J, Burns, C, Banerjee, A, Morrison, M, Pfeffercorn, C, Ritchie, A, Buhr, H, Eccleston, M, Parke, R, Bell, J, Newby, L, Henderson, S, Mehrtens, J, Kalkoff, M, West, C, Morgan, J, Rudder, L, Sutton, J, Garrett, P, Groves, N, McDonald, S, Jennifer Palmer, A, Joyce, C, Harwood, M, Helyar, J, Mackie, B, Lipman, J, Boots, R, Bertenshaw, C, Deans, R, Fourie, C, Lassig-Smith, M, Flabouris, A, Edwards, J, O'Connor, S, Rivett, J, Turner, A, Field, T, Marsden, K, Mathlin, C, Goldsmith, D, Mercer, I, O'Sullivan, K, Edington, J, Boschert, C, Smith, J, Ihle, B, Graan, M, Ho, S, Botha, J, Fowler, N, McInness, J, Pratt, N, and Orford, N

Abstract

Introduction: Current practice in the delivery of caloric intake (DCI) in patients with severe acute kidney injury (AKI) receiving renal replacement therapy (RRT) is unknown. We aimed to describe calorie administration in patients enrolled in the Randomized Evaluation of Normal vs. Augmented Level of Replacement Therapy (RENAL) study and to assess the association between DCI and clinical outcomes.Methods: We performed a secondary analysis in 1456 patients from the RENAL trial. We measured the dose and evolution of DCI during treatment and analyzed its association with major clinical outcomes using multivariable logistic regression, Cox proportional hazards models, and time adjusted models.Results: Overall, mean DCI during treatment in ICU was low at only 10.9 ± 9 Kcal/kg/day for non-survivors and 11 ± 9 Kcal/kg/day for survivors. Among patients with a lower DCI (below the median) 334 of 729 (45.8%) had died at 90-days after randomization compared with 316 of 727 (43.3%) patients with a higher DCI (above the median) (P = 0.34). On multivariable logistic regression analysis, mean DCI carried an odds ratio of 0.95 (95% confidence interval (CI): 0.91-1.00; P = 0.06) per 100 Kcal increase for 90-day mortality. DCI was not associated with significant differences in renal replacement (RRT) free days, mechanical ventilation free days, ICU free days and hospital free days. These findings remained essentially unaltered after time adjusted analysis and Cox proportional hazards modeling.Conclusions: In the RENAL study, mean DCI was low. Within the limits of such low caloric intake, greater DCI was not associated with improved clinical outcomes. © 2014 Bellomo et al.; licensee BioMed Central Ltd.

Published
2014

5. Management of blood glucose in the critically ill in Australia and New Zealand: A practice survey and inception cohort study.

Author

Dale S., Browne T., Peake S., Cade J., Boyce C., Hicks P., Durham D., French C., Little L., Wood J., Mitchell I., Finfer S., Bellomo R., Higlett T., McArthur C., Newby L., Goldsmith D., Bates S., Sutherland T., Reece G., Gopalakrisanan M., Tamhane R., Milliss D., Hunt T., Beca J., Ginger T., Richards B., Tallot M., Fratzia J., McFadyen B., Cook P., Rudder L., Lister L., Cole I., Weisbrodt L., Liang J., Hore C., Mullany D., Shehabi Y., Adamson H., Stephens D., Thomas J., Bell T., Marsden K., Totaro R., Rajbhandari D., Myburgh J., Santamaria J., Dale S., Browne T., Peake S., Cade J., Boyce C., Hicks P., Durham D., French C., Little L., Wood J., Mitchell I., Finfer S., Bellomo R., Higlett T., McArthur C., Newby L., Goldsmith D., Bates S., Sutherland T., Reece G., Gopalakrisanan M., Tamhane R., Milliss D., Hunt T., Beca J., Ginger T., Richards B., Tallot M., Fratzia J., McFadyen B., Cook P., Rudder L., Lister L., Cole I., Weisbrodt L., Liang J., Hore C., Mullany D., Shehabi Y., Adamson H., Stephens D., Thomas J., Bell T., Marsden K., Totaro R., Rajbhandari D., Myburgh J., and Santamaria J.

Abstract

Objective: To document current management of blood glucose in Australian and New Zealand intensive care units (ICUs) and to investigate the association between insulin administration, blood glucose concentration and hospital outcome. Design and setting: Practice survey and inception cohort study in closed multi-disciplinary ICUs in Australia and New Zealand. Patient(s): Twenty-nine ICU directors and 939 consecutive admissions to 29 ICUs during a 2-week period. Measurement and results: Data collected included unit approaches to blood glucose management, patient characteristics, blood glucose concentrations, insulin administration and patient outcomes. Ten percent of the ICU directors reported using an intensive insulin regimen in all their patients. In 861 patients (91.7%) blood glucose concentration was greater than 6.1 mmol/l, 287 (31.1%) received insulin, and the median blood glucose concentration triggering insulin administration was 11.5 (IQR 9.4-14) mmol/l. Univariate analysis demonstrated that non-survivors had a higher maximum daily blood glucose concentration (12 mmol/l, 9.4-14.8, vs. 9.5, 7.6-12.2) and were more likely to receive insulin (47% vs. 28%). Multiple logistic regression analysis showed age (OR per 5-year decrease 0.93, 95% CI 0.87-1.00) and APACHE II (OR per point decrease 0.87, 95% CI 0.84-0.90) to be independently associated with hospital mortality. After controlling for age and APACHE II both daily highest blood glucose (OR 0.95, 95% CI 0.90-1.00) and administration of insulin (OR 0.62, 95% CI 0.39-1.00) were independently associated when added to the model alone; neither was independently associated when they were simultaneously included in the model. Conclusion(s): Few Australian and New Zealand ICUs have adopted intensive insulin therapy. In this study, insulin administration and highest daily blood glucose concentration could not be separated in their association with hospital mortality. © Springer-Verlag 2006.

Published
2006

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