Economic evaluation of continuous renal replacement therapy in acute renal failure

Objectives:Controversy exists regarding the optimal method of providing dialysis in critically ill patients with acute renal failure. We sought to determine the cost-effectiveness of treatment strategies.Methods:Adult subjects requiring renal replacement therapy in a critical care setting who are candidates for intermittent hemodialysis (IHD) or continuous renal replacement therapy (CRRT) were considered within a Markov model. Alternative strategies including IHD, and standard or high dose CRRT were compared. The model considered relevant clinical and economic outcomes, and incorporated data on clinical effectiveness from a recent systematic review and high quality micro-costing data.Results:In the base-case analysis, CRRT was associated with similar health outcomes but higher costs by ($3,679 more than IHD per patient). In scenarios considering alternate cost sources, and higher intensity of IHD (including daily and longer duration IHD), CRRT remained more costly. Sensitivity analysis indicated that even small differences in the risk of mortality or need for long-term chronic dialysis therapy among surviving patients benefits led to dramatic changes in the cost-effectiveness of the modalities considered.Conclusions:Given the higher costs of providing CRRT and absence of demonstrated benefit, IHD is the preferred modality in critically ill patients who are candidates for either IHD or CRRT, although this conclusion should be revisited if future clinical trials establish differences in clinical effectiveness between modalities. Future interventions that are proven to improve renal recovery after acute renal failure are likely to be cost-effective, even if very resource intensive.

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Metabolic and Nutritional Aspects of Acute Renal Failure in Critically Ill Patients Requiring Continuous Renal Replacement Therapy

Nutrition in Clinical Practice ◽

10.1177/0115426505020002176 ◽

2005 ◽

Vol 20 (2) ◽

pp. 176-191 ◽

Cited By ~ 72

Author(s):

Jennifer A. Wooley ◽

Imad F. Btaiche ◽

Kelley L. Good

Keyword(s):

Renal Failure ◽

Acute Renal Failure ◽

Renal Replacement Therapy ◽

Continuous Renal Replacement Therapy ◽

Replacement Therapy ◽

Critically Ill ◽

Critically Ill Patients

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Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients*

Critical Care Medicine ◽

10.1097/00003246-200209000-00016 ◽

2002 ◽

Vol 30 (9) ◽

pp. 2051-2058 ◽

Cited By ~ 595

Author(s):

Philipp G. H. Metnitz ◽

Claus G. Krenn ◽

Heinz Steltzer ◽

Thomas Lang ◽

Jürgen Ploder ◽

...

Keyword(s):

Renal Failure ◽

Acute Renal Failure ◽

Renal Replacement Therapy ◽

Replacement Therapy ◽

Critically Ill ◽

Critically Ill Patients

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Effect of Nosocomial Bloodstream Infection on the Outcome of Critically Ill Patients with Acute Renal Failure Treated with Renal Replacement Therapy

Journal of the American Society of Nephrology ◽

10.1097/01.asn.0000110182.14608.0c ◽

2004 ◽

Vol 15 (2) ◽

pp. 454-462 ◽

Cited By ~ 63

Author(s):

E. A. J. Hoste

Keyword(s):

Renal Failure ◽

Acute Renal Failure ◽

Renal Replacement Therapy ◽

Replacement Therapy ◽

Bloodstream Infection ◽

Critically Ill ◽

Critically Ill Patients ◽

Nosocomial Bloodstream Infection

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Use of a Low-Molecular-Weight Heparinoid (Danaparoid Sodium) for Continuous Renal Replacement Therapy in Intensive Care Patients

Clinical and Applied Thrombosis/Hemostasis ◽

10.1177/107602960100700409 ◽

2001 ◽

Vol 7 (4) ◽

pp. 300-304 ◽

Cited By ~ 25

Author(s):

Edelgard Lindhoff-Last ◽

Christoph Betz ◽

Rupen Bauersachs

Keyword(s):

Renal Failure ◽

Acute Renal Failure ◽

Intensive Care ◽

Renal Replacement Therapy ◽

Replacement Therapy ◽

Critically Ill ◽

Critically Ill Patients ◽

Infusion Rate ◽

Efficient Treatment ◽

Intensive Care Patients

The purpose of this study was to evaluate the efficacy and safety of danaparoid in the treatment of critically ill patients with acute renal failure and suspected heparin-induced thrombocytopenia (HIT) needing renal replacement therapy (RRT). We conducted a retrospective analysis of 13 consecutive intensive care patients with acute renal failure and suspected HIT who were treated with danaparoid for at least 3 days during RRT. In eight patients, continuous venovenous hemofiltration was performed. The mean infusion rate of danaparoid was 140 ± 86 U/hour. Filter exchange was necessary every 37.5 hours. In five patients, continuous venovenous hemodialysis was used. A bolus injection of 750 U danaparoid was followed by a mean infusion rate of 138 ± 122 U/hour. Filters were exchanged every 24 hours. In 7 of 13 patients, even a low mean infusion rate of 88 ± 35 U/hour was efficient. Mean anti-Xa (aXa) levels were approximately 0.4 ± 0.2 aXa U/mL. Persistent thrombocytopenia despite discontinuation of heparin treatment was observed in 9 of 13 patients, owing to disseminated intravascular coagulation (DIC). HIT was confirmed by an increase in platelet count and positive heparin-induced antibodies in 2 of 13 patients. No thromboembolic complications occurred, but major bleeding was observed in 6 of 13 patients, which could be explained by consumption of coagulation factors and platelets due to DIC in 5 of 6 patients. Nine of 13 patients died of multiorgan failure or sepsis, or both. In none of these patients was the fatal outcome related to danaparoid treatment. In critically ill patients with renal impairment and suspected HIT, a bralus injection of 750 U danaparoid followed by a mean infusion rate of 50 to 150 U/hour appears to be a safe and efficient treatment option when alternative anticoagutation is necessary.

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A Prospective Study of Continuous Venovenous Hemodiafiltration in Critically Ill Patients with Acute Renal Failure

Journal of Intensive Care Medicine ◽

10.1177/088506669501000405 ◽

1995 ◽

Vol 10 (4) ◽

pp. 187-192 ◽

Cited By ~ 8

Author(s):

Rinaldo Bellomo ◽

Michael Farmer ◽

Neil Boyce

Keyword(s):

Renal Failure ◽

Acute Renal Failure ◽

Intensive Care ◽

Renal Replacement Therapy ◽

Confidence Interval ◽

Replacement Therapy ◽

Critically Ill ◽

Critically Ill Patients ◽

Apache Ii Score ◽

Continuous Venovenous Hemodiafiltration

We studied the biochemical and the clinical consequences of the application of continuous venovenous hemodiafiltration to the management of acute renal failure in critically ill patients. One hundred consecutive surgical and medical ICU patients with acute renal failure were entered into a prospective clinical study at an intensive care unit of tertiary institution. Intervention included assessment of illness severity by APACHE II score on admission and by organ failure score prior to initiation of renal replacement therapy; treatment of patients with continuous venovenous hemodiafiltration; and measurement of biochemical variables prior to and after therapy. Outcome assessment included incidence of complications, duration of oliguria, duration of intensive care and hospital stays, and survival to hospital discharge. Measurements and main results included the following: mean patient age was 60.9 years (range 21–81 yr); mean APACHE II score, 28.6 (95% confidence interval; 27.4-29.8); and number of failing organs, mean, 4.1 (95% confidence interval; 3.8-4.4). At commencement of continuous venovenous hemofiltration with dialysis, 79% of patients were receiving inotropic drugs and 72% were septic, and, in 35%, bacteremia or fungemia was demonstrated. Renal replacement therapy was applied for a mean duration of 186.2 hours (95% confidence interval; 149.2-223.7), with a mean hourly net ultrafiltrate production of 621 mL (95% confidence interval; 594–648) and a mean urea clearance of 28.1 mL/min (95% confidence interval; 26.7-29.5). Azotemia was controlled in all patients (plasma urea < 30 mmol/L). During the more than 18,000 hours of treatment, there was no therapy-associated hemodynamic instability. Complications were rare. They included two cases of hemofilter rupture with minor blood loss and a single case of bleeding at the site of the vascular-access catheter. Forty-three patients survived to ICU discharge, and 40 survived to hospital discharge. Continuous venovenous hemodiafiltration is a safe and an effective form of renal replacement therapy in critically ill patients. In such patients, who have a high predicted mortality rate, it was associated with a 40% survival rate. These findings suggests that continuous venovenous hemodiafiltration may be ideally suited to patients with multisystem organ failure with acute renal failure.

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