Elsevier

The Lancet

Volume 368, Issue 9533, 29 July–4 August 2006, Pages 379-385
The Lancet

Articles
Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial

https://doi.org/10.1016/S0140-6736(06)69111-3Get rights and content

Summary

Background

Whether continuous renal replacement therapy is better than intermittent haemodialysis for the treatment of acute renal failure in critically ill patients is controversial. In this study, we compare the effect of intermittent haemodialysis and continuous venovenous haemodiafiltration on survival rates in critically ill patients with acute renal failure as part of multiple-organ dysfunction syndrome.

Methods

Our prospective, randomised, multicentre study took place between Oct 1, 1999, and March 3, 2003, in 21 medical or multidisciplinary intensive-care units from university or community hospitals in France. Guidelines were provided to achieve optimum haemodynamic tolerance and effectiveness of solute removal in both groups. The two groups were treated with the same polymer membrane and bicarbonate-based buffer. 360 patients were randomised, and the primary endpoint was 60-day survival based on an intention-to-treat analysis.

Findings

Rate of survival at 60-days did not differ between the groups (32% in the intermittent haemodialysis group versus 33% in the continuous renal replacement therapy group [95 % CI −8·8 to 11·1,]), or at any other time.

Interpretation

These data suggest that, provided strict guidelines to improve tolerance and metabolic control are used, almost all patients with acute renal failure as part of multiple-organ dysfunction syndrome can be treated with intermittent haemodialysis.

Introduction

Since the first description of continuous arteriovenous haemofiltration in 1977, continuous renal replacement therapy has gained wide acceptance for the treatment of acute renal failure in intensive care.1 Proponents of continuous renal replacement therapy commonly advocate that continuous techniques provide better haemodynamic stability than with intermittent haemodialysis. Since improved systemic haemodynamics might be associated with fewer episodes of renal ischaemia, continuous renal replacement therapy might reduce the time to recovery of renal function and even result in increased survival.2

Whether or not continuous renal replacement therapy improves outcome compared with intermittent haemodialysis is controversial. Several groups have compared both methods, but mostly in non-randomised, retrospective trials,3, 4, 5, 6, 7, 8 which often compared continuous renal replacement therapy using synthetic membranes with intermittent haemodialysis with cuprophan membranes.3, 4, 5, 6, 7 These groups showed a trend toward improved survival with continuous renal replacement therapy despite raised severity scores in this group. Three prospective randomised studies comparing continuous renal replacement therapy with intermittent haemodialysis were inconclusive.9, 10, 11 Mehta and colleagues9 reported higher death rates in their continuous renal replacement therapy group; however, the two groups were unbalanced for several covariates that are independently associated with mortality (sex, hepatic failure, and organ system failure and acute physiology and chronic health evaluation III [APACHE III] scores) in favour of intermittent haemodialysis. After adjustment for these covariates, there was no difference in death rates between the two treatments. The two other studies did not show any survival improvement with continuous renal replacement therapy, but these studies were under powered.10, 11 Two recent meta-analyses12, 13 also did not show any significant difference in outcome between patients given continuous renal replacement therapy and intermittent haemodialysis.

In addition to limitations inherent to the retrospective and uncontrolled design of most of these studies, other factors including the technique of continuous renal replacement therapy, the use of different membranes, and the absence of standardisation of dialysis protocols preclude meaningful interpretation of these results. Our aim was, therefore, to compare the effect of continuous renal replacement therapy and intermittent haemodialysis with polyacrylonitrile membranes on survival in patients with acute renal failure as part of multiple-organ dysfunction syndrome.

Section snippets

Patients

From Oct 1, 1999, to March 3, 2003, we did a prospective randomised, non-blinded trial in 21 medical or multidisciplinary intensive-care units from university or community hospitals in France. The selected centres routinely used continuous renal replacement therapy and intermittent haemodialysis to treat acute renal failure in acutely ill patients. The study was approved by the local ethics committee and was regulated by an independent data safety and monitoring board. We obtained written

Results

Figure 1 shows the trial profile and table 1 the baseline characteristics of the participants. Treatment modalities are shown in table 2. On the basis of mean dialysis flow, mean ultrafiltration flow, and weight, and accounting for the predilutional infusion, the average dose of continuous venovenous haemodiafiltration was 29 mL/kg per h (SD 11) (table 2). There are no available data for dialysis dose in intermittent haemodialysis group. The mean number of intermittent haemodialysis sessions

Discussion

In this randomised study, we compared continuous venovenous haemodiafiltration with intermittent haemodialysis for the treatment of acute renal failure in multiple-organ-dysfunction syndrome and showed no difference in survival at any time, incidence and time to recovery of renal function, or occurrence of adverse events (apart from hypothermia). In view of the long hospital stay of critically ill patients with multiple-organ-dysfunction syndrome, the primary endpoint of the study was 60-day

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