Acute Kidney Injury: ATN (Acute Renal Failure Trial Network Study )

Question 1

ATN Clinical Question

Answer 1

In critically ill patients with acute tubular necrosis, does more intensive renal replacement therapy decrease the risk of death at 60 days compared to conventional less-intensive renal replacement therapy?

Question 2

ATN bottom line

Answer 2

In critically ill patients with acute tubular necrosis, more intensive renal replacement therapy does not improve all-cause mortality at 60 days compared to conventional less-intensive therapy. In the ATN study, intensive RRT did not improve renal function or nonrenal organ dysfunction, although it was associated with more frequent hypotensive episodes.

Question 3

ATN primary outcome

Answer 3

All-cause mortality at 60 days

Question 4

ATN inclusion criteria

Answer 4

-Age ≥18 years -Admitted to ICU -Acute tubular necrosis, defined by: —Clinically apparent ischemia or nephrotoxic injury and One or more of —– oliguria (average urine output < 20 ml/hr for >24 hours), —-or increased serum creatinine ongoing for less than 4 days (increased to >177 umol/L [2 mg/dl] for men and >133 umol/L [1.5 mg/dl] for women) -Investigator must have been planning to initiate renal replacement therapy -Failure of one or more non-renal organs (SOFA score ≥2) or sepsis

Question 5

ATN interventions

Answer 5

Patients were randomized to intensive or conventional less intensive renal replacement therapy. Within each group, the ATN protocol defined when to use an intermittent therapy (IHD) or a continuous therapy (CVVHDF or SLED) based on the SOFA score. Patients with a SOFA score of ≤2 were treated with intermittent hemodialysis. Those with SOFA scores of 3-4 were treated with one of the continuous therapies. The choice between the two continuous therapy options was left to local clinicians. Therefore, although different modalities were used in ATN, this study only examined the effect of treatment intensity. Intensive renal replacement therapy Intermittent hemodialysis or sustained low-efficiency dialysis: 6 treatments per week with goal Kt/Vurea of 1.2-1.4 per session Continuous venovenous hemodiafiltration (CVVHDF): Prescribed total effluent flow rate of 35 ml/kg/hour Conventional renal replacement therapy Intermittent hemodialysis or sustained low-efficiency dialysis: 3 treatments per week with goal Kt/Vurea of 1.2-1.4 per session Continuous venovenous hemodiafiltration (CVVHDF): Prescribed total effluent flow rate of 20 ml/kg/hour

Question 6

ATN sub group finding

Answer 6

There was a trend observed among septic patients towards a benefit with conventional RRT. This is contrary to previous opinion which has held that patients suffering from sepsis would be the most likely to benefit from intensive RRT

Question 7

ATN Criticisms

Answer 7

Timing of RRT initiation was not standardized A dynamic dosing approach may have been more appropriate for these individuals with a disease that dynamically changes in severity The outcomes may be biased because of the prolonged duration from ICU admission to enrollment, lack of consideration of fluid balance, and high rate of treatment with CRRT before randomization It is unclear why the renal recovery rate was so low Men were overrepresented in the study, likely attributable to the fact that 25% of patients enrolled were from VA centers Generalizability also limited by exclusion of patients with baseline advanced CKD