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  • Dialytrauma

    Dialytrauma


    • Dialytrauma refers to the set of possible and non-desired complications associated with the use of renal-replacement therapies (RRT).

      The Dialytrauma Concept was introduced into medical literature in 2008 by a Spanish group of intensivists. The idea was born as a consequence of the publication of the first major trial (known as the ATN Study) looking at the intensity of renal support in critically ill patients with acute kidney injury (AKI). In this multicenter, randomized, controlled trial, renal support was delivered using different RRT modalities: intermittent hemodialysis, sustained low-efficiency dialysis, or continuous venovenous hemodiafiltration. The main result of this study (including 1,124 patients) was that a fixed “intensive” dose (35 mL/Kg/h) delivered with different RRT modalities, produced the same clinical outcomes than a “less-intensive” dose (20 mL/Kg/h). The authors’ conclusion was that critically ill patients with AKI requiring RRT should be treated with this “less-intensive” dose, given that it will achieve the same results as the “intensive” one. Nevertheless, the rate of complications and adverse events detected was higher in the “intensive” dose arm of this study. As such, the aforementioned Spanish group of intensivists, wrote a letter to the Editor of the same Journal[2] postulating the idea that all those complications (grouped under the term “Dialytrauma”) could have been responsible for the results of the ATN Study. In the same letter to the Editor, and according to what had been previously published by Dr. Schiffl, they hypothesized that a dynamic adjustment of the dose of RRT, would be more physiological due to the dynamic nature of AKI in critical illness. This therapeutic schedule, named “Dynamic Approach”, would reduce the incidence of dialytrauma and, probably, would achieve better clinical outcomes.

      However, given the lack of level 1 clinical trials on this “Theory of Dynamic Approach”, the authors of the ATN Study branded this idea as being “speculative”. Despite this, a year later Dr. Palevsky (ATN Study’s first author) wrote an Editorial comment on the RENAL Study (the second major trial looking at the intensity of renal support) concluding that the:

      Failure to demonstrate improved outcomes with more intensive renal-replacement therapy in critically ill patients […] does not imply that the intensity of renal-replacement therapy does not matter. [...] Furthermore, it should not be forgotten that patient care needs to be individualized – more intensive therapy may be required for the treatment of hyperkalemia, metabolic acidosis, or extreme hypercatabolism – and that the true adequacy of renal-replacement therapy is defined by more than just the clearance of small solutes.



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