Abstract
Different Prescribed Doses of High Volume Peritoneal Dialysis and Outcome of Patients with Acute Kidney Injury
Objective: It has not been clearly shown which modality of dialysis is superior in the management of acute kidney injury (AKI). The optimal dialysis dose for the treatment of AKI is controversial No studies have directly examined the effects of the peritoneal dialysis (PD) dose on outcome in AKI.
Methods: We randomly assigned critically ill patients with AKI to receive higher or lower intensity PD therapy (prescribed Kt/V 0.8 and 0.5 per session respectively) from January 2005 to January 2007. PD dose was calculated in patients treated exclusively with continuous PD 7 times/week using a Tenckhoff catheter and a cycler. The main outcome measures were death within 30 days, recovery of kidney function and metabolic control.
Results: Of the 61 enrolled patients, 30 were randomly assigned to higher intensity therapy and 31 to lower intensity PD dose. The 2 study groups had similar baseline characteristics and received the treatment for 6.1 and 5.7 days respectively (p=0.42). At 30 days after randomization, 17 deaths had occurred in the higher intensity group (55%) and 16 deaths in the lower intensity group (53%), p=0.83. At 30 day, 9% of survivors in the higher and lower intensity (1/14) were still receiving renal replacement therapy (p=0.72). There was significant difference between the 2 groups in prescribed versus delivered PD dose (higher intensity group 0.8×0.59, p=0.04; lower intensity group 0.5×0.49, p=0.89) and the 2 groups had similar metabolic control after 4 PD sessions (BUN levels of 69.3±14.4 and 60.3±11.1 respectively, p=0.71).
Conclusions: Intensive PD dose in critically ill patients with AKI did not decrease mortality, improve recovery of kidney function or metabolic control, and PD dose is limited by dialysate flow and membrane permeability and clearance per exchange can be decreased if a shorter dwell time is applied.
High Volume Peritoneal Dialysis (PD) versus Sustained Low Efficiency Dialysis: A Randomized Controlled Trial in Patients with Acute Kidney Injury: Initial Results
Objective: Sustained low efficiency dialysis (SLED) is much utilized in acute kidney injury (AKI) and PD is used in the developed world. Recently we demonstrated that high volume PD (HVPD) and daily hemodialysis are comparable methods. Purpose: This is a double-center prospective, randomized controlled trial to compare the effect of HVPD versus SLED on AKI patient (pt) survival, beginning in 2008 in Clinical Hospital of Botucatu and General Hospital of Bauru, Sao Paulo, Brazil. Methods: We calculated that with at least 180 pts, study statistical power will be 80% to detect an absolute difference in mortality of 20% between the groups. The primary end point will be pt mortality in 60 days. Eligible subjects are critically ill adults with AKI (defined according to AKIN) due to acute tubular necrosis who require use of vasoactive drugs in Intensive Care Unit. Pts with severe hypercatabolism are excluded. After enrollment, pts are randomly assigned to either the HVPD or SLED group. A HVPD session is defined as 24 hours of dialysis 7 days/week using an automated cycler, and a SLED session is defined as 6–8 hours performed 6 days/week with hemodialysis machine. Results: After 15 months, 179 pts were eligible for enrollment. 56 pts were withdrawn (18 HVPD and 38 SLED) because they had died during first dialysis session or the method was modified. Of the remaining 123 pts (68.3% of the calculated), 52 received HVPD and 71 SLED. The pts’ characteristics are similar: male (HVPD=70.8% and SLED=70.1%), age (60.9±18 and 67.8±10 years), internal medicine (70% and 65%), ATN-ISS score (0.74 and 0.61), BUN (94±20 and 90±30 mg/dL), serum creatinine (5.8±3.3 and 4.5±1.7 mg/dL), and ischemic AKI (85% and 87%). Delivered dialysis dose, ultrafiltration per session, and metabolic control had been not yet analyzed. Overall mortality rates were similar for both groups (65.4% and 77.4%). Of the pts who survived, 47% HVPD and 50% SLED recovered renal function after 60 days. Conclusions: The initial results show that HVPD and SLED can be effective methods for treating AKI pts.