Weaning of Renal Replacement Therapy in Critically Ill Patients With Acute Kidney Injury: Predictive Performance of Urinary Parameters
试验速览
- 阶段
- 不适用
- 状态
- 尚未招募
- 入组人数
- 600
- 试验地点
- 3
- 主要终点
- Number of RRT-free days at D30 with at least 7 consecutive days alive and without RRT
研究概览
简要总结
Data on the optimal period for RRT weaning in critically ill patient are scarce. The current practice for RRT weaning is based on urine output, the threshold of which is debatable. Two recent observational studies have shown that an increase in urinary creatinine or urea concentrations is a better predictive marker of RRT weaning than urine output.
An unjustified delay in RRT weaning leads to numerous complications such as catheter-related infections, delay of the patient's functional recovery, severe ionic disorder, bleeding, and induced hemodynamic instability. It also induces an increase workload for careers and in cost without any additional benefit for the patient. Conversely, too early weaning inevitably limits the prevention on fluid accumulation that is independently associated with an increased risk of mortality and inevitably leads to resumption of RRT requiring reinsertion of dialysis catheter resulting in potential complications.
A multicentre randomized controlled trial will be then necessary and only able to identify the optimal RRT weaning strategy.
The main objective is to compare two RRT weaning strategies on RRT duration in critically ill patients with acute kidney injury: a strategy based on combined criteria (urine output + urinary parameters) as compared to a single strategy based only on urine output.
The study protocol will be an open-label, two parallel group, multicenter, randomized, controlled clinical trial, in which enrolled ICU adult patients will have RRT weaning based either on urine output alone (single strategy) or on urine output and urinary parameters (combined strategy).
When the urine output is greater than 500ml/24h, the enrollment must be performed within 24hours in 2 groups:.
" Single strategy ": In the single strategy, RRT weaning will be achieved when urine output exceeds 500ml/24h without diuretics or 2000ml/24h with diuretics use.
" Combined strategy": In the combined strategy, when urine output exceeds 500ml/day with or without diuretic use, RRT will be stopped during 48h to assess urinary indices (urinary creatinine and urea). Soon as urinary indices are higher than thresholds values (urinary creatinine > 5.2mmol/day and urinary urea > 1.35mmol/kg/day, RRT will be weaned. If they are lower, a RRT session will be perform after which the weaning process will be resume.
The primary endpoint is the number of RRT-free days at D30 with at least 7 consecutive days alive and without RRT.
详细描述
RRT is an invasive high-cost treatment with potentially severe complications. However, there is a major dearth of data on RRT weaning in the ICU. The weaning strategy using only urine output is based on scarce and debatable data. The two observational studies concluded independently that the urinary concentration of creatinine or urea would be able to predict RRT weaning. These new data propose a novel combined strategy based on urine output and urinary parameters which are more specific to renal recovery and potentially better suited to determine the optimal period of RRT weaning.
This trial aims to determine the best RRT weaning strategy and so indirectly to determine the optimal duration of RRT in the ICU. Our trial methodology is able to determine clearly if one of the two weaning strategies is more effective and will lead to more health benefits and fewer risks for ICU patients.It is an open-label, two parallel group, multicenter, randomized, controlled clinical trial, in which enrolled ICU adult patients will have RRT weaning based either on urine output alone (single strategy) or on urine output and urinary parameters (combined strategy).
Critically ill patients aged 18 and over, admitted to the ICU, receiving or having received invasive mechanical ventilation and/or catecholamine infusion at least 48h, with acute kidney injury, at KDIGO 3 stage associated with oliguria at least < 200ml/ 24h before RRT initiation, treated with intermittent or continuous renal replacement therapy and resumption of urine output > 300ml/24h with or without diuretic use; will be included in the study.
Enrolled patients will be randomized into two groups, the single strategy or the combined strategy. When the urine output is greater than 500ml/24h, the enrollment must be performed within 24hours:
"Single strategy": RRT weaning will be achieved when urine output exceeds 500ml/24h without diuretics or 2000ml/24h with diuretics use.
研究设计
- 研究类型
- Interventional
- 分配方式
- Randomized
- 干预模型
- Parallel
- 主要目的
- Treatment
- 盲法
- None
入排标准
- 年龄范围
- 18 Years 至 —（Adult, Older Adult）
- 性别
- All
- 接受健康志愿者
- 否
入选标准
- •Adults (18 years of age or older)
- •Admitted to the ICU
- •Receiving or having received invasive mechanical ventilation and/or catecholamine infusion (epinephrine or norepinephrine or dobutamine) at least 48h
- •With acute kidney injury, at KDIGO 3 (See Appendix 1) stage and associated with oliguria at least < 200ml/ 24h before RRT initiation
- •Treated with intermittent or continuous renal replacement therapy
- •Resumption of urine output > 300ml/24h with or without diuretic use
排除标准
- •Preexisting Chronic kidney disease with estimated glomerular filtration rate (eGFR) < 30ml/min
- •AKI caused by vascular occlusion, glomerulonephritis, vasculitis, post-renal obstruction, thrombotic microangiopathy, tumor lysis syndrome
- •RRT for another cause than AKI (eg: drug intoxication,...)
- •Decision to forgo life-sustaining treatment including RRT
- •Cirrhosis with Child-Pugh score of C or hepatorenal syndrome
- •Kidney transplantation
- •Patient already enrolled in the study
- •Participation in another clinical trial assessing the impact or duration of RRT
- •Pregnancy in progress or planned during the study period or breastfeeding women
- •Patients protected by law (Art. L1121-6 and L1121-8 of the Code de la Santé Publique) : Adult protected by law or patient under guardianship or curatorship
- •Subjects not covered by public health insurance
- •Absence of written informed consent from the patient or his or her proxy (if present) before inclusion or when possible when the patient has been included in an emergency setting
结局指标
主要结局
Number of RRT-free days at D30 with at least 7 consecutive days alive and without RRT
时间窗: Day30
Days without RRT
次要结局
- Number of RRT resumption between inclusion and Day30(between inclusion and Day30)
- Rate of dialysis catheter-related colonization in ICU(Day30)
- Incidence of hypokalemia with and without clinical complications in ICU(Day30)
- Incidence of hypophosphatemia with and without clinical complications in ICU(Day30)
- Incidence of hyponatremia with and without clinical complications in ICU(Day30)
- Rate of bleeding and etiologies in ICU(Day30)
- Number of days with mechanical ventilation and high-flow nasal cannula oxygen therapy in ICU(Day30)
- Number of RRT weaned days at Day90(Day90)
- Renal recovery at Day30(Day30)
- Serum Creatinine and urea at ICU discharge(Day of ICU discharge)
- Number of days in ICU and hospital within Day90(within Day90)
- Rate of ICU, hospital and Day90 mortality(Day90)
- Costs related to RRT and ICU stay within Day90(within Day90)
- Number of RRT sessions in ICU and at Day90(in ICU and at Day90)
- Renal recovery at Day90(Day90)
- Serum Creatinine and urea at Day90(Day90)
- Rate of dialysis catheter-related infection in ICU(Day30)
- Rate of documented gastric ulcers in ICU(Day30)
- Rate of nosocomial infections in ICU(Day30)
- Number of days with vasopressors treatment in ICU(Day30)
- Nadir of serum bicarbonate in ICU(Day30)
- Incidence of hyperphosphatemia with and without clinical complications in ICU(Day30)
- Incidence of hypernatremia with and without clinical complications in ICU(Day30)
- Rate of cardio-vascular events in ICU(Day30)
- Rate of severe hypoxemia related to fluid overload(Day30)
- Incidence of hyperkalemia with and without clinical complications in ICU(Day30)