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Background: Continuous renal replacement therapy (CRRT) is commonly employed in the intensive care unit (ICU), though there are no guidelines around the transition between CRRT and intermittent hemodialysis (iHD). Accelerated venovenous hemofiltration (AVVH) is a modality utilizing higher hemofiltration rates (4–5 L/h) with shorter session durations (8–10 h) to “accelerate” the clearance and volume removal that normally is spread out over a 24-h period in CRRT. We examined AVVH as a transition therapy between CRRT and iHD, with the aim of decreasing time on CRRT and providing a more graduated transition for hemodynamically unstable patients requiring RRT. Methods: Retrospective cohort study describing the clinical outcomes and quality initiative experience of the integration of AVVH into the CRRT program at an academic tertiary care center. Outcomes of interest included mortality, ICU length of stay and readmission rates, and technical characteristics of treatments. Results: In total, 97 patients received a total of 298 AVVH treatments (3.1 ± 3.3 treatments per patient). Totally, 271/298 (91%) treatments were completed successfully. During an average treatment time of 9.5 ± 1.6 h with 4.2 ± 0.5 L/h -replacement fluid rate, urea reduction ratio was 23 ± 26% per 10-h treatment, and net ultrafiltration volume was 2.4 ± 1.3 L/treatment. Inpatient mortality was 32%, mean total hospital length of stay was 54 ± 47 days. Sixty-four out of 97 (66%) patients recovered renal function by discharge. Among those who transferred out of the ICU, 7/62 (11%) patients required readmission to the ICU after developing hypotension on iHD. Conclusion: AVVH can serve as a transition therapy between CRRT and iHD in the ICU and has the potential to decrease total time on CRRT, improve patient mobility, and sustain low ICU readmission rates. Future study is needed to analyze the implications on resource use and cost of this modality.

1.
Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu H, Morgera S, et al.; Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) Investigators. Acute renal failure in critically ill patients: a multinational, multicenter study.
JAMA
. 2005 Aug;294(7):813–8.
2.
Demirjian S, Chertow GM, Zhang JH, O’Connor TZ, Vitale J, Paganini EP, et al.; VA/NIH Acute Renal Failure Trial Network. Model to predict mortality in critically ill adults with acute kidney injury.
Clin J Am Soc Nephrol
. 2011 Sep;6(9):2114–20.
3.
Bellomo R, Ronco C, Mehta RL, Asfar P, Boisramé-Helms J, Darmon M, et al. Acute kidney injury in the ICU: from injury to recovery: reports from the 5th Paris International Conference.
Ann Intensive Care
. 2017 Dec;7(1):49.
4.
Allegretti AS, Steele DJ, David-Kasdan JA, Bajwa E, Niles JL, Bhan I. Continuous renal replacement therapy outcomes in acute kidney injury and end-stage renal disease: a cohort study.
Crit Care
. 2013 Jun;17(3):R109.
5.
Tolwani A. Continuous renal-replacement therapy for acute kidney injury.
N Engl J Med
. 2012 Dec;367(26):2505–14.
6.
Augustine JJ, Sandy D, Seifert TH, Paganini EP. A randomized controlled trial comparing intermittent with continuous dialysis in patients with ARF.
Am J Kidney Dis
. 2004 Dec;44(6):1000–7.
7.
Bouchard J, Soroko SB, Chertow GM, Himmelfarb J, Ikizler TA, Paganini EP, et al.; Program to Improve Care in Acute Renal Disease (PICARD) Study Group. Fluid accumulation, survival and recovery of kidney function in critically ill patients with acute kidney injury.
Kidney Int
. 2009 Aug;76(4):422–7.
8.
Overberger P, Pesacreta M, Palevsky PM; VA/NIH Acute Renal Failure Trial Network. Management of renal replacement therapy in acute kidney injury: a survey of practitioner prescribing practices.
Clin J Am Soc Nephrol
. 2007 Jul;2(4):623–30.
9.
Lins RL, Elseviers MM, Van der Niepen P, Hoste E, Malbrain ML, Damas P, et al.; SHARF investigators. Intermittent versus continuous renal replacement therapy for acute kidney injury patients admitted to the intensive care unit: results of a randomized clinical trial.
Nephrol Dial Transplant
. 2009 Feb;24(2):512–8.
10.
Vinsonneau C, Camus C, Combes A, Costa de Beauregard MA, Klouche K, Boulain T, et al.; Hemodiafe Study Group. Continuous venovenous haemodiafiltration versus intermittent haemodialysis for acute renal failure in patients with multiple-organ dysfunction syndrome: a multicentre randomised trial.
Lancet
. 2006 Jul;368(9533):379–85.
11.
Rabindranath K, Adams J, Macleod AM, Muirhead N. Intermittent versus continuous renal replacement therapy for acute renal failure in adults.
Cochrane Database Syst Rev
. 2007 Jul;(3):CD003773.
12.
Srisawat N, Lawsin L, Uchino S, Bellomo R, Kellum JA; BEST Kidney Investigators. Cost of acute renal replacement therapy in the intensive care unit: results from The Beginning and Ending Supportive Therapy for the Kidney (BEST Kidney) study.
Crit Care
. 2010;14(2):R46.
13.
Schwenger V, Weigand MA, Hoffmann O, Dikow R, Kihm LP, Seckinger J, et al. Sustained low efficiency dialysis using a single-pass batch system in acute kidney injury - a randomized interventional trial: the REnal Replacement Therapy Study in Intensive Care Unit PatiEnts.
Crit Care
. 2012 Jul;16(4):R140.
14.
Bagshaw SM, Darmon M, Ostermann M, Finkelstein FO, Wald R, Tolwani AJ, et al. Current state of the art for renal replacement therapy in critically ill patients with acute kidney injury.
Intensive Care Med
. 2017 Jun;43(6):841–54.
15.
Nates JL, Nunnally M, Kleinpell R, Blosser S, Goldner J, Birriel B, et al. ICU Admission, Discharge, and Triage Guidelines: A Framework to Enhance Clinical Operations, Development of Institutional Policies, and Further Research.
Crit Care Med
. 2016 Aug;44(8):1553–602.
16.
Hua M, Wunsch H. The complexities of ICU discharge.
Chest
. 2015 Feb;147(2):281–2.
17.
Strijack B, Mojica J, Sood M, Komenda P, Bueti J, Reslerova M, et al. Outcomes of chronic dialysis patients admitted to the intensive care unit.
J Am Soc Nephrol
. 2009 Nov;20(11):2441–7.
18.
Gashti CN, Salcedo S, Robinson V, Rodby RA. Accelerated venovenous hemofiltration: early technical and clinical experience.
Am J Kidney Dis
. 2008 May;51(5):804–10.
19.
Rhodes A, Evans LE, Alhazzani W, Levy MM, Antonelli M, Ferrer R, et al. Surviving Sepsis Campaign: International Guidelines for Management of Sepsis and Septic Shock: 2016.
Intensive Care Med
. 2017 Mar;43(3):304–77.
20.
Knaus WA, Draper EA, Wagner DP, Zimmerman JE. APACHE II: a severity of disease classification system.
Crit Care Med
. 1985 Oct;13(10):818–29.
21.
Le Gall JR, Lemeshow S, Saulnier F. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study.
JAMA
. 1993 Dec;270(24):2957–63.
22.
Higgins TL, Teres D, Copes WS, Nathanson BH, Stark M, Kramer AA. Assessing contemporary intensive care unit outcome: an updated Mortality Probability Admission Model (MPM0-III).
Crit Care Med
. 2007 Mar;35(3):827–35.
23.
Vincent JL, Moreno R, Takala J, Willatts S, De Mendonça A, Bruining H, et al. The SOFA (Sepsis-related Organ Failure Assessment) score to describe organ dysfunction/failure. On behalf of the Working Group on Sepsis-Related Problems of the European Society of Intensive Care Medicine.
Intensive Care Med
. 1996 Jul;22(7):707–10.
24.
Joannidis M, Oudemans-van Straaten HM. Clinical review: patency of the circuit in continuous renal replacement therapy.
Crit Care
. 2007;11(4):218.
25.
Macedo E, Mehta RL. Continuous Dialysis Therapies: core Curriculum 2016.
Am J Kidney Dis
. 2016 Oct;68(4):645–57.
26.
Scheetz MH, Scarsi KK, Ghossein C, Hurt KM, Zembower TR, Postelnick MJ. Adjustment of antimicrobial dosages for continuous venovenous hemofiltration based on patient-specific information.
Clin Infect Dis
. 2006 Feb;42(3):436–7.
27.
Trotman RL, Williamson JC, Shoemaker DM, Salzer WL. Antibiotic dosing in critically ill adult patients receiving continuous renal replacement therapy.
Clin Infect Dis
. 2005 Oct;41(8):1159–66.
28.
Kuang D, Verbine A, Ronco C. Pharmacokinetics and antimicrobial dosing adjustment in critically ill patients during continuous renal replacement therapy.
Clin Nephrol
. 2007 May;67(5):267–84.
29.
Lewis SJ, Kays MB, Mueller BA. Use of Monte Carlo Simulations to Determine Optimal Carbapenem Dosing in Critically Ill Patients Receiving Prolonged Intermittent Renal Replacement Therapy.
J Clin Pharmacol
. 2016 Oct;56(10):1277–87.
30.
Sherman RA, Cody RP, Rogers ME, Solanchick JC. Accuracy of the urea reduction ratio in predicting dialysis delivery.
Kidney Int
. 1995 Jan;47(1):319–21.
31.
Uchino S, Bellomo R, Morimatsu H, Morgera S, Schetz M, Tan I, et al.; Beginning and Ending Supportive Therapy for the Kidney (B.E.S.T. Kidney) Investigators. External validation of severity scoring systems for acute renal failure using a multinational database.
Crit Care Med
. 2005 Sep;33(9):1961–7.
32.
Delannoy B, Floccard B, Thiolliere F, Kaaki M, Badet M, Rosselli S, et al. Six-month outcome in acute kidney injury requiring renal replacement therapy in the ICU: a multicentre prospective study.
Intensive Care Med
. 2009 Nov;35(11):1907–15.
33.
Bellomo R, Cass A, Cole L, Finfer S, Gallagher M, Lo S, et al.; RENAL Replacement Therapy Study Investigators. Intensity of continuous renal-replacement therapy in critically ill patients.
N Engl J Med
. 2009 Oct;361(17):1627–38.
34.
Palevsky PM, Zhang JH, O’Connor TZ, Chertow GM, Crowley ST, Choudhury D, et al.; VA/NIH Acute Renal Failure Trial Network. Intensity of renal support in critically ill patients with acute kidney injury.
N Engl J Med
. 2008 Jul;359(1):7–20.
35.
Gashti CN, Rodby RA, Huang Z, Gao D, Zhang W. Effects of high blood flow and high pre-dilution replacement fluid rates on small solute clearances in hemofiltration.
Blood Purif
. 2011;32(4):266–70.
36.
Venkataraman R, Kellum JA, Palevsky P. Dosing patterns for continuous renal replacement therapy at a large academic medical center in the United States.
J Crit Care
. 2002 Dec;17(4):246–50.
37.
Sherman RA. We Lower Blood Flow for Intradialytic Hypotension.
Semin Dial
. 2016 Jul;29(4):295–6.
38.
Zhang L, Yang J, Eastwood GM, Zhu G, Tanaka A, Bellomo R. Extended Daily Dialysis Versus Continuous Renal Replacement Therapy for Acute Kidney Injury: A Meta-analysis.
Am J Kidney Dis
. 2015 Aug;66(2):322–30.
39.
Edrees F, Li T, Vijayan A. Prolonged Intermittent Renal Replacement Therapy.
Adv Chronic Kidney Dis
. 2016 May;23(3):195–202.
40.
Abe M, Okada K, Suzuki M, Nagura C, Ishihara Y, Fujii Y, et al. Comparison of sustained hemodiafiltration with continuous venovenous hemodiafiltration for the treatment of critically ill patients with acute kidney injury.
Artif Organs
. 2010 Apr;34(4):331–8.
41.
Albino BB, Balbi AL, Abrão JM, Ponce D. Dialysis complications in acute kidney injury patients treated with prolonged intermittent renal replacement therapy sessions lasting 10 versus 6 hours: results of a randomized clinical trial.
Artif Organs
. 2015 May;39(5):423–31.
42.
Lonnemann G, Floege J, Kliem V, Brunkhorst R, Koch KM. Extended daily veno-venous high-flux haemodialysis in patients with acute renal failure and multiple organ dysfunction syndrome using a single path batch dialysis system.
Nephrol Dial Transplant
. 2000 Aug;15(8):1189–93.
43.
Ponzoni CR, Corrêa TD, Filho RR, Serpa Neto A, Assunção MS, Pardini A, et al. Readmission to the Intensive Care Unit: Incidence, Risk Factors, Resource Use, and Outcomes. A Retrospective Cohort Study.
Ann Am Thorac Soc
. 2017 Aug;14(8):1312–9.
44.
Flythe JE, Xue H, Lynch KE, Curhan GC, Brunelli SM. Association of mortality risk with various definitions of intradialytic hypotension.
J Am Soc Nephrol
. 2015 Mar;26(3):724–34.
45.
Neyra JA, Li X, Canepa-Escaro F, Adams-Huet B, Toto RD, Yee J, et al.; Acute Kidney Injury in Critical Illness Study Group. Cumulative Fluid Balance and Mortality in Septic Patients With or Without Acute Kidney Injury and Chronic Kidney Disease.
Crit Care Med
. 2016 Oct;44(10):1891–900.
46.
Marshall MR, Creamer JM, Foster M, Ma TM, Mann SL, Fiaccadori E, et al. Mortality rate comparison after switching from continuous to prolonged intermittent renal replacement for acute kidney injury in three intensive care units from different countries.
Nephrol Dial Transplant
. 2011 Jul;26(7):2169–75.
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