Determining the Optimal Time for LibEration from Renal Replacement Therapy in Critically Ill Patients: A Systematic Review and Meta-Analysis (DOnE RRT)
CCCF ePoster library. Katulka J. Nov 9, 2018; 233408
Dr. Jeremy Katulka
Dr. Jeremy Katulka
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Abstract
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Introduction:

Renal replacement therapy (RRT) is a complex and expensive form of life-sustaining therapy, reserved for our most acutely ill patients. While a number of randomized trials have evaluated the optimal timing to start RRT among critically ill patients in the ICU, there has been a paucity of trials providing guidance on when and under what circumstances to ideally liberate a patient from RRT.1,2,3 

 

Objectives:

To conduct a systematic review and meta-analysis of available evidence on clinical and biochemical markers that predict renal recovery and successful liberation from acute RRT among critically ill patients with acute kidney injury (AKI).

 

Methods:

A comprehensive search strategy was developed in consultation with a research librarian and independently peer-reviewed by a second librarian. Electronic databaseses (Ovid Medline, Ovid Embase and Wiley Cochrane Library) were searched, as were selected grey literature sources. Our search strategy focused on concepts related to RRT (i.e., intermittent hemodialysis (IHD), slow low-efficiency dialysis (SLED), continuous renal replacement therapy (CRRT)); intensive care medince (i.e., involving any intensive care unit (ICU) setting) and discontinuation of therapy (i.e., either clinical, physiological and biochemical parameters of weaning acute RRT). Citation screening, selection, quality assessment and data abstraction were performed in duplicate. Studies were pooled in statistical meta-analysis when deemed sufficiently clinically homogenous, with sensitivities and specificities pooled simultaneously using a hierarchical summary receiver operator characteristic curve (HSROC) and bi-variate analysis.

 

Results:

Our search yielded 3031 results, of which 20 studies fulfilled eligibility; 18 cohort studies and 2 case control studies, evaluating a total of 3650 patients (Figure 1). Studies were assessed for quality and risk of bias using the Newcastle-Ottawa Score (NOS). The mean NOS score was 7 (range 4-9) and the majority of studies were of high quality (n=16, 80%) with 4 studies rated as moderate quality (20%). There were no studies identified as being poor quality. The most commonly identified parameter was urine output, identified in 9 studies (45%), followed by serum Cystatin C, which was identified in 3 studies (15%). Other identified biomarkers included kinetic eGFR, plasma NGAL, urine urea, creatinine clearance (2- and 24- hour), NT-proBNP and multivariate models including baseline parameters, each identified in a single instance. However, all identified parameters exhibited significant heterogeneity between studies.

 

Conclusion:

20 studies were identified evaluating clinical and biochemical parameters of weaning RRT in critically ill patients with AKI. Urine output and serum cystatin C were the most commonly identified parameters, although definitions and cutoff values were heterogenous between studies. Further study is required to better define cutoffs and clarify the role of various biomarkers and elucidate accurate predictive models of RRT weaning in the critically ill patient population. Future work will involve quantitative analysis of the various identified weaning parameters.

 


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