Article Text

  1. T. S. Wheeler1,
  2. A. J. Tolwani1
  1. 1Division of Nephrology, University of Alabama at Birmingham, Birmingham, AL.


Purpose Continuous renal replacement therapy (CRRT) is increasingly used to manage acute renal failure (ARF) in the intensive care unit (ICU). There are no specific guidelines to help determine the optimal time for discontinuation of CRRT. The decision to stop CRRT has traditionally been based on an increase in the urine output in conjunction with an improving hemodynamic profile; however, an adequate urine output is not always accompanied by improved solute clearance. Ideally, CRRT should be discontinued when sufficient intrinsic renal recovery has occurred. Unwarranted CRRT increases the cost of ICU care and risk for complications, including bleeding, hypotension, and catheter-related sepsis. We evaluated the utility of a 24-hour urine collection for creatinine clearance (CrCl), obtained while on CRRT, as a means to guide discontinuation of therapy.

Methods We retrospectively evaluated ICU patients who had a 24-hour urine CrCl performed when they became nonoliguric while on CRRT. CRRT discontinuation was deemed successful if patients maintained adequate metabolic and volume status for at least 2 weeks following removal of CRRT.

Results A total of 23 patients were identified. All patients had a baseline creatinine of < 1.4 mg/dL and were oliguric (urine output < 400 mL/24 h) at initiation of CRRT. Of the 23 patients, 9 had a 24-hour CrCl > 15 mL/min prior to CRRT discontinuation, whereas 14 had a 24-hour urine CrCl < 15 mL/min. Baseline characteristics between the two groups were not statistically significant. At cessation of CRRT, there were no significant differences in mean serum creatinine (2.3 ± 8 vs 1.8 ± 1.0 mg/dL) or mean urine output (1,581 ± 856 vs 1,139 ± 672 mL) between the CrCl > 15 mL/min and CrCl < 15 mL/min groups. Eight of nine (89%) patients in the CrCl > 15 mL/min group successfully remained off RRT for at least 2 weeks following CRRT discontinuation, whereas only 4 of 14 (29%) patients in the CrCl < 15 mL/min group successfully remained off RRT (p = .009). The positive predictive value of a 24-hour urine CrCl > 15 mL/min for remaining off CRRT is 89%; the negative predictive value of a 24-hour urine CrCl < 15 mL/min is 71%. The area under the ROC curve is 0.81. Curve characteristics demonstrate that a threshold CrCl > 15 mL/min predicts successful discontinuation of CRRT.

Conclusion Our data suggest that a 24-hour urine CrCl > 15 mL/min, collected while on CRRT, predicts renal recovery and may help guide cessation of CRRT.

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