etal.CriticalCare2013,17:445/content/17/4/445 LETTER Timingofrenalreplacementtherapy:isitwhenorhowmuch?
TejaMahadeshwar1,HansolKim1,AshishTikotekar*2andAmayParikh2,
3 SeerelatedresearchbyLeiteetal.,/content/17/2/R62 Leiteandcolleaguesaddressedtheimportanceofearlyinitiationofrenalreplacementtherapy(RRT)indecreasingmortalityandICUlengthofstayinpatientswithAcuteKidneyInjuryNetworkstage3[1];however,wehaveafewconcernsregardingthestudy. eimpactoffluidbalanceonmorbidityandmortalityinpatientswithsepticshock,especiallywithacutekidneyinjury,cannotbeunderstated[2].isimpactcanaffectventilator-freedaysandthelengthofICUstay.eauthorsdidnotshowtheirfirst6-hourand24-hourfluidbalances. WhetherthereportedimprovementwasduetothetimingofinitiationofRRT,thedose,ormisrepresentation ofthestudypopulationisanunansweredquestion.WereimprovementsseeninmorbidityandmortalitysimplybecausemorevolumewasremovedbecauseofearlyinitiationofRRTorbecausepatientswithmoreseverediseasewerenotrepresentedinthestudy?
eoverallin-hospitalmortalityinthisstudywas72%,whichisextremelyhigh.Inpreviousprospectivestudies,theoverallmortalityratewasjust46%[3].Werethereothervariablesinmanagementthatwerenotaddressed,suchasthetimefromadmissiontoantibiotictreatment,adequatefluidresuscitation,orinitiationvasopressortreatment,whichmayhaveledtothehighmortalityinthispopulation[4]?
Authors’response TacyanoTavaresLeiteandAlexandreBragaLibório WeappreciatetheinterestofDrMahadeshwarandcolleaguesinourpaper.First,regardingtheimpactoffluidbalanceinmortality,weconsiderthiswasonelimitationofourstudyasstatedintheDiscussionsection:‘Anotherlimitationisthelackofdataonfluidbalance,makingitespeciallydifficulttoexplorereasonsforreducedmechanicalventilationtimeinearlyRRTpatients’[1]. Regardingthemortalityofourpatients,the46%mortalityratecitedbyMahadeshwarandcolleaguesreferstothemortalityamongsepticpatientshavingornothavingacutekidneyinjury.Inourpaper,onlypatientsrequiringRRTwereincludedandthemajorityofpatientshadsepsis.ChouandcolleaguesdisclosedasimilarmortalityrateinsepticpatientsneedingRRT[5]. AbbreviationsRRT,renalreplacementtherapy. CompetinginterestsTheauthorsdeclarethattheyhavepetinginterests. Authordetails1InternalMedicineDivision,DepartmentofMedicine,RobertWoodJohnsonMedicalSchool,1RobertWoodJohnsonPlace,POBox19,NewBrunswick,NJ08903-0019,USA.2PulmonaryandCriticalCareDivision,Departmentof *Correspondence:ashtik@2PulmonaryandCriticalCareDivision,DepartmentofMedicine,RobertWoodJohnsonMedicalSchool,1RobertWoodJohnsonPlace,POBox19,NewBrunswick,NJ08903-0019,USAFulllistofauthorinformationisavailableattheendofthearticle ©2010BioMedCentralLtd ©2013BioMedCentralLtd Medicine,RobertWoodJohnsonMedicalSchool,1RobertWoodJohnsonPlace,POBox19,NewBrunswick,NJ08903-0019,USA.3NephrologyDivision,DepartmentofMedicine,RobertWoodJohnsonMedicalSchool,1RobertWoodJohnsonPlace,POBox19,NewBrunswick,NJ08903-0019,USA. Published:1August2013 References1.LeiteTT,MacedoE,PereiraSM,BandeiraSR,PontesPH,GarciaAS,MilitaoFR, SobrinhoIM,AssuncaoLM,LiborioAB:TimingofrenalreplacementtherapyinitiationbyAKINclassicationsystem.CritCare2013,17:R62.2.BagshawSM,BrophyPD,CruzD,RoncoC:Fluidbalanceasabiomarker:impactofuidoverloadoneincriticallyillpatientswithacutekidneyinjury.CritCare2008,12:169.3.Brun-BuissonC,DoyonF,CarletJ,DellamonicaP,GouinF,LepoutreA,MercierJC,OenstadtG,RegnierB:Incidence,riskfactors,andeofseveresepsisandsepticshockinadults.Amulticenterprospectivestudyinintensivecareunits.FrenchICUGroupforSevereSepsis.JAMA1995,274:968-974. Mahadeshwaretal.CriticalCare2013,17:445/content/17/4/445 Page2of2
4.RiversE,NguyenB,HavstadS,ResslerJ,MuzzinA,KnoblichB,PetersonE,TomlanovichM,EarlyGoal-DirectedTherapyCollaborativeG:Earlygoal-directedtherapyinthetreatmentofseveresepsisandsepticshock.NEnglJMed2001,345:1368-1377.
5.ChouYH,HuangTM,WuVC,WangCY,ShiaoCC,LaiCF,TsaiHB,ChaoCT,YoungGH,WangWJ,KaoTW,LinSL,HanYY,ChouA,LinTH,YangYW,ChenYM,TsaiPR,LinYF,HuangJW,ChiangWC,ChouNK,KoWJ,WuKD,TsaiTJ;NSARFStudyGroup:Impactoftimingofrenalreplacementtherapyinitiationoneofsepticacutekidneyinjury.CritCare2011,15:R134. doi:12797Citethisarticleas:MahadeshwarT,etal.:Timingofrenalreplacementtherapy:isitwhenorhowmuch?
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