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A Hierarchical End Point Analysis of the Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney
Dana Y Fuhrman1,2, Katja M Gist3, Ayse Akcan Arikan4,5
1Division of Critical Care Medicine, Cincinnati Children's Hospital Medical Center, Cincinnati, Ohio.
Insights
Early liberation trials for pediatric patients on continuous renal replacement therapy (CRRT) with adequate urine output are linked to better outcomes. Assessing readiness for CRRT liberation by day 5 shows promise for improved patient recovery.
Area of Science:
- Pediatric Nephrology
- Critical Care Medicine
- Renal Replacement Therapy
Background:
- Limited data exist on assessing readiness for continuous renal replacement therapy (CRRT) liberation in children.
- Hierarchical composite endpoints have not been previously applied in this pediatric CRRT setting.
Purpose of the Study:
- To evaluate if a trial of CRRT liberation in pediatric patients with preserved urine output is associated with improved outcomes.
- To utilize a hierarchical composite endpoint approach for assessing CRRT liberation readiness.
Main Methods:
- Retrospective cohort study of pediatric patients (≤25 years) from the WE-ROCK registry.
- Included patients with urine output >0.5 mL/kg/hour for ≥24 hours within 5 days of CRRT initiation.
- Primary exposure: CRRT liberation trial by day 5. Primary outcome: Hierarchical composite of 90-day mortality, 90-day kidney replacement therapy dependence, ICU-free days, and hospital-free days. Analyzed using inverse probability weighting and win ratio analysis.
Main Results:
- 192 of 366 eligible patients (53%) underwent a liberation trial by day 5.
- Patients undergoing a liberation trial were older, had higher creatinine, and lower illness severity.
- A liberation trial was associated with improved hierarchical outcomes (win ratio, 2.14; p <0.001), primarily due to increased ICU- and hospital-free days.
Conclusions:
- A trial of CRRT liberation by day 5 in pediatric patients with preserved urine output is linked to better outcomes.
- Supports early assessment of liberation readiness in pediatric CRRT patients exhibiting adequate urine output (>0.5 mL/kg/hour).
Key Points:
Early trial of liberation from continuous renal replacement therapy was associated with improved patient-important clinical outcomes in children with preserved urine output. Hierarchical composite end point analysis demonstrated greater intensive care unit and hospital-free days among patients who underwent a liberation trial. These findings supported early assessment of readiness for liberation using urine output to guide decision making for children receiving continuous renal replacement therapy.
Background:
Data to guide assessment of readiness for liberation from continuous renal replacement therapy (CRRT) in children are limited, and hierarchical composite end points have not been applied in this setting. We evaluated whether performing a trial of CRRT liberation among patients with preserved urine output is associated with improved outcomes using a hierarchical end point approach.
Methods:
We conducted a retrospective cohort study of patients aged≤25 years from the multicenter Worldwide Exploration of Renal Replacement Outcomes Collaborative in Kidney Disease registry. Patients with urine output >0.5 ml/kg per hour for≥24 hours within the first 5 days after CRRT initiation were included. The primary exposure was a trial of CRRT liberation by day 5. The primary outcome was a hierarchical composite of: ( 1 ) 90-day mortality, ( 2 ) 90-day KRT dependence, ( 3 ) intensive care unit-free days, and ( 4 ) hospital-free days. Inverse probability weighting was used to balance baseline characteristics, and outcomes were compared using a win ratio analysis.
Results:
Among 366 eligible patients, 192 (53%) underwent a liberation trial by day 5. These patients were older, had higher reference serum creatinine levels, and exhibited lower illness severity when compared with those who did not undergo a trial of liberation. In adjusted analyses, a liberation trial was associated with an improved hierarchical outcome (win ratio, 2.14 [95% confidence interval, 1.56 to 2.94], P < 0.001), driven primarily by greater intensive care unit- and hospital-free days.
Conclusion:
Among CRRT recipients with preserved urine output, a trial of liberation by day 5 was associated with improved outcomes, supporting the early assessment of liberation readiness in patients with a urine output >0.5 ml/kg per hour.
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