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Title: Heterogeneity of Effect of Net Ultrafiltration Rate among Critically Ill Adults Receiving Continuous Renal Replacement Therapy.
Austin Authors: Serpa Neto, Ary ;Naorungroj, Thummaporn ;Murugan, Raghavan;Kellum, John A;Gallagher, Martin;Bellomo, Rinaldo 
Affiliation: Intensive Care
Centre for Integrated Critical Care, The University of Melbourne, Melbourne, Victoria, Australia
Department of Intensive Care, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand,.
Department of Critical Care Medicine, University of Pittsburgh School of Medicine Pittsburgh, Pittsburgh, Pennsylvania, USA
Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modelling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
Department of Critical Care Medicine, Hospital Israelita Albert Einstein, São Paulo, Brazil
Data Analytics Research and Evaluation (DARE) Centre
Department of Critical Care Medicine, The Center for Critical Care Nephrology, University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania, USA
Department of Nephrology, The George Institute for Global Health and University of Sydney, Sidney, New South Wales, Australia
Department of Intensive Care, Amsterdam University Medical Centers, Location "AMC", Amsterdam, The Netherlands
Issue Date: 7-Oct-2020 2020-10-07
Publication information: Blood Purification 2020; online first: 7 October
Abstract: In continuous renal replacement therapy (CRRT)-treated patients, a net ultrafiltration (NUF) rate >1.75 mL/kg/h has been associated with increased mortality. However, there may be heterogeneity of effect of NUF rate on mortality, according to patient characteristics. To investigate the presence and impact of heterogeneity of effect, we performed a secondary analysis of the "Randomized Evaluation of Normal versus Augmented Level of Renal Replacement Therapy" (RENAL) trial. Exposure was NUF rate (weight-adjusted fluid volume removed per hour) stratified into tertiles (<1.01 mL/kg/h; 1.01-1.75 mL/kg/h; or >1.75 mL/kg/h). Primary outcome was 90-day mortality. Patients were clustered according to baseline characteristics. Heterogeneity of effect was assessed according to clusters and baseline edema and related to the additional impact of baseline cardiovascular Sequential Organ Failure Assessment (SOFA) score. We excluded patients with missing values for baseline weight and/or treatment duration. We identified 2 clusters. The largest (cluster 1; n = 941) included more severely ill patients, with more sepsis, more edema, and more vasopressor therapy (all p < 0.001). Compared to the middle tertile, the probability of harm was greater with the high tertile of NUF rate in patients in cluster 1 and in patients with baseline edema (probability of harm, cluster 1: 99.9%; edema: 99.1%). Moreover, higher baseline cardiovascular SOFA score also increased mortality risk with both high and low compared to middle NUF rates in cluster 1 patients and in patients with edema. In CRRT patients, both high and low NUF rates may be harmful, especially in those with edema, sepsis, and greater illness severity. Cardiovascular SOFA scores modulate this association. Additional studies are needed to test these hypotheses, and targeted trials of NUF rates based on risk stratification appear justified. identifier: NCT00221013.
DOI: 10.1159/000510556
PubMed URL: 33027799
Type: Journal Article
Subjects: Acute kidney injury
Continuous renal replacement therapy
Fluid balance
Net ultrafiltration rate
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