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<p>Observational studies link high net ultrafiltration (UF<sub>NET</sub>) rates during continuous kidney replacement therapy (CKRT) to increased mortality. The Restrictive versus Liberal Rate of Extracorporeal Volume Evaluation in Acute Kidney Injury trial evaluated the feasibility of a restrictive versus liberal UF<sub>NET</sub> rate strategy. This stepped-wedge cluster-randomized trial enrolled patients in ten ICUs across two healthcare systems from July 2022 to June 2024. Each ICU was a cluster, with 1 randomly transitioning from liberal (2.0–5.0 mL/kg/h) to restrictive (0.5–1.5 mL/kg/h) group every two months after the first six months. The coprimary outcomes included between-group separation in UF<sub>NET</sub> rates, protocol adherence, and recruitment rate. Of 97 patients (55 liberal, 42 restrictive) enrolled, the mean (SD) delivered UF<sub>NET</sub> rate did not differ between the groups (2.05 [0.83] vs. 1.81 [0.86] mL/kg/h; adjusted <i>P</i> = 0.4). In per-protocol analysis, there was a significant between-group separation in mean UF<sub>NET</sub> rates (2.24 [0.72] vs. 1.22 [0.32] mL/kg/h; <i>P</i> = 0.002). Protocol deviations were similar (9.1% vs.7.1%, <i>P</i> = 0.7), and the recruitment rate was 0.99 (0.27) patients per ICU per two months. The use of rescue UF<sub>NET</sub> was higher in the restrictive group (14.5% vs. 66.7%; <i>P</i> &lt; 0.001). In conclusion, despite high protocol adherence, there was minimal separation in delivered UF<sub>NET</sub> rates. While both strategies were feasible in select patients, the high rates of hemodynamic instability, the need for rescue UF<sub>NET,</sub> and physician override orders suggest that UF<sub>NET</sub> is more often driven by dynamic patient physiology than fixed protocols. This makes it challenging to maintain distinct, alternative UF<sub>NET</sub> targets in clinical practice.</p><p><?noindent??><b>Trial registration number</b>: ClinicalTrials.gov Identifier: NCT05306964.</p>

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Alternative net ultrafiltration rate strategies in acute kidney injury: a feasibility randomized clinical trial

  • 期刊论文

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  • 发表日期：

    2026年4月22日

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  • Raghavan Murugan,
  • Victor Talisa,
  • Chung-Chou H. Chang,
  • Nasrin Nikravangolsefid,
  • Waryaam Singh,
  • Brad W. Butcher,
  • Ali Al-Khafaji,
  • Scott Gunn,
  • Firas Abdulmajeed,
  • Phillip Lamberty,
  • David Huang,
  • Paul M. Palevsky,
  • Kianoush Kashani,
  • Michele Elder,
  • Maham Raza,
  • Denise Scholl,
  • Tina Vita,
  • William Sabol,
  • Dan Ricketts,
  • Thomas Mathie,
  • Linda Stevanus-Schmadel,
  • Anna Woodall,
  • Mashiyat Ahmed,
  • Jonathan Bishop,
  • Justin Patri,
  • Waaryam Singh,
  • Andrea Katah,
  • Supawadee Supadungsuk,
  • Tom Sanger,
  • Kathleen Liu,
  • Ashita Tolwani,
  • Manisha Jhamb,
  • Dana Fuhrman,
  • Hsing-Hua Sylvia Lin,
  • Susan Sandusky,
  • Sammy Massimino,
  • Ivonne Schulman,
  • Raghavan Murugan,
  • Victor Talisa,
  • Chung-Chou H. Chang,
  • Nasrin Nikravangolsefid,
  • Waryaam Singh,
  • Brad W. Butcher,
  • Ali Al-Khafaji,
  • Scott Gunn,
  • Firas Abdulmajeed,
  • Phillip Lamberty,
  • David Huang,
  • Paul M. Palevsky,
  • Kianoush Kashani

摘要

Observational studies link high net ultrafiltration (UFNET) rates during continuous kidney replacement therapy (CKRT) to increased mortality. The Restrictive versus Liberal Rate of Extracorporeal Volume Evaluation in Acute Kidney Injury trial evaluated the feasibility of a restrictive versus liberal UFNET rate strategy. This stepped-wedge cluster-randomized trial enrolled patients in ten ICUs across two healthcare systems from July 2022 to June 2024. Each ICU was a cluster, with 1 randomly transitioning from liberal (2.0–5.0 mL/kg/h) to restrictive (0.5–1.5 mL/kg/h) group every two months after the first six months. The coprimary outcomes included between-group separation in UFNET rates, protocol adherence, and recruitment rate. Of 97 patients (55 liberal, 42 restrictive) enrolled, the mean (SD) delivered UFNET rate did not differ between the groups (2.05 [0.83] vs. 1.81 [0.86] mL/kg/h; adjusted P = 0.4). In per-protocol analysis, there was a significant between-group separation in mean UFNET rates (2.24 [0.72] vs. 1.22 [0.32] mL/kg/h; P = 0.002). Protocol deviations were similar (9.1% vs.7.1%, P = 0.7), and the recruitment rate was 0.99 (0.27) patients per ICU per two months. The use of rescue UFNET was higher in the restrictive group (14.5% vs. 66.7%; P < 0.001). In conclusion, despite high protocol adherence, there was minimal separation in delivered UFNET rates. While both strategies were feasible in select patients, the high rates of hemodynamic instability, the need for rescue UFNET, and physician override orders suggest that UFNET is more often driven by dynamic patient physiology than fixed protocols. This makes it challenging to maintain distinct, alternative UFNET targets in clinical practice.

Trial registration number: ClinicalTrials.gov Identifier: NCT05306964.