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Published in: Intensive Care Medicine 3/2024

26-02-2024 | Coma | Original

Renal replacement therapy initiation strategies in comatose patients with severe acute kidney injury: a secondary analysis of a multicenter randomized controlled trial

Authors: Thomas Rambaud, David Hajage, Didier Dreyfuss, Saïd Lebbah, Laurent Martin-Lefevre, Guillaume Louis, Sébastien Moschietto, Dimitri Titeca-Beauport, Béatrice La Combe, Bertrand Pons, Nicolas De Prost, Sébastien Besset, Alain Combes, Adrien Robine, Marion Beuzelin, Julio Badie, Guillaume Chevrel, Julien Bohe, Elisabeth Coupez, Nicolas Chudeau, Saber Barbar, Christophe Vinsonneau, Jean-Marie Forel, Didier Thevenin, Eric Boulet, Karim Lakhal, Nadia Aissaoui, Steven Grange, Marc Leone, Guillaume Lacave, Saad Nseir, Florent Poirson, Julien Mayaux, Karim Ashenoune, Guillaume Geri, Kada Klouche, Guillaume Thiery, Laurent Argaud, Bertrand Rozec, Cyril Cadoz, Pascal Andreu, Jean Reignier, Jean-Damien Ricard, Jean-Pierre Quenot, Romain Sonneville, Stéphane Gaudry

Published in: Intensive Care Medicine | Issue 3/2024

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Abstract

Purpose

The effect of renal replacement therapy (RRT) in comatose patients with acute kidney injury (AKI) remains unclear. We compared two RRT initiation strategies on the probability of awakening in comatose patients with severe AKI.

Methods

We conducted a post hoc analysis of a trial comparing two delayed RRT initiation strategies in patients with severe AKI. Patients were monitored until they had oliguria for more than 72 h and/or blood urea nitrogen higher than 112 mg/dL and then randomized to a delayed strategy (RRT initiated after randomization) or a more-delayed one (RRT initiated if complication occurred or when blood urea nitrogen exceeded 140 mg/dL). We included only comatose patients (Richmond Agitation-Sedation scale [RASS] < − 3), irrespective of sedation, at randomization. A multi-state model was built, defining five mutually exclusive states: death, coma (RASS < − 3), incomplete awakening (RASS [− 3; − 2]), awakening (RASS [− 1; + 1] two consecutive days), and agitation (RASS >  + 1). Primary outcome was the transition from coma to awakening during 28 days after randomization.

Results

A total of 168 comatose patients (90 delayed and 78 more-delayed) underwent randomization. The transition intensity from coma to awakening was lower in the more-delayed group (hazard ratio [HR] = 0.36 [0.17–0.78]; p = 0.010). Time spent awake was 10.11 days [8.11–12.15] and 7.63 days [5.57–9.64] in the delayed and the more-delayed groups, respectively. Two sensitivity analyses were performed based on sedation status and sedation practices across centers, yielding comparable results.

Conclusion

In comatose patients with severe AKI, a more-delayed RRT initiation strategy resulted in a lower chance of transitioning from coma to awakening.
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Literature
16.
go back to reference Vinsonneau C, Allain-Launay E, Blayau C et al (2015) Renal replacement therapy in adult and pediatric intensive care: recommendations by an expert panel from the French Intensive Care Society (SRLF) with the French Society of Anesthesia Intensive Care (SFAR) French Group for Pediatric Intensive Care Emergencies (GFRUP) the French Dialysis Society (SFD). Ann Intensive Care 5:58. https://doi.org/10.1186/s13613-015-0093-5CrossRefPubMedPubMedCentral Vinsonneau C, Allain-Launay E, Blayau C et al (2015) Renal replacement therapy in adult and pediatric intensive care: recommendations by an expert panel from the French Intensive Care Society (SRLF) with the French Society of Anesthesia Intensive Care (SFAR) French Group for Pediatric Intensive Care Emergencies (GFRUP) the French Dialysis Society (SFD). Ann Intensive Care 5:58. https://​doi.​org/​10.​1186/​s13613-015-0093-5CrossRefPubMedPubMedCentral
Metadata
Title
Renal replacement therapy initiation strategies in comatose patients with severe acute kidney injury: a secondary analysis of a multicenter randomized controlled trial
Authors
Thomas Rambaud
David Hajage
Didier Dreyfuss
Saïd Lebbah
Laurent Martin-Lefevre
Guillaume Louis
Sébastien Moschietto
Dimitri Titeca-Beauport
Béatrice La Combe
Bertrand Pons
Nicolas De Prost
Sébastien Besset
Alain Combes
Adrien Robine
Marion Beuzelin
Julio Badie
Guillaume Chevrel
Julien Bohe
Elisabeth Coupez
Nicolas Chudeau
Saber Barbar
Christophe Vinsonneau
Jean-Marie Forel
Didier Thevenin
Eric Boulet
Karim Lakhal
Nadia Aissaoui
Steven Grange
Marc Leone
Guillaume Lacave
Saad Nseir
Florent Poirson
Julien Mayaux
Karim Ashenoune
Guillaume Geri
Kada Klouche
Guillaume Thiery
Laurent Argaud
Bertrand Rozec
Cyril Cadoz
Pascal Andreu
Jean Reignier
Jean-Damien Ricard
Jean-Pierre Quenot
Romain Sonneville
Stéphane Gaudry
Publication date
26-02-2024
Publisher
Springer Berlin Heidelberg
Published in
Intensive Care Medicine / Issue 3/2024
Print ISSN: 0342-4642
Electronic ISSN: 1432-1238
DOI
https://doi.org/10.1007/s00134-024-07339-1

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