(1415) Hemodynamic Instability During Renal Replacement Therapy in the Critically Ill: A Systematic Review

Introduction: Hemodynamic instability during renal replacement therapy (HIRRT) occurs frequently in critically ill patients, however definitions of HIRRT in the literature vary widely. This heterogeneity poses challenges for understanding the impact of HIRRT on clinical outcomes. The aim of this systematic review is to evaluate the association between HIRRT and clinical outcomes in randomized controlled trials (RCTs), as well as compare rates of HIRRT according to various definitions.

Methods: Multiple databases were comprehensively searched for relevant RCTs examining renal replacement therapy (RRT) or RRT-related interventions in critically ill patients with acute kidney injury. Articles were included if they reported rates of HIRRT, as well as mortality or renal recovery. In accordance with PRISMA guidelines, article screening, data extraction and quality assessment were performed independently in duplicate, with conflicts resolved by discussion or a third reviewer.

Results: The search yielded 6675 articles, of which 31 studies were included in the review after full text screening. 18 articles provided a formal definition of HIRRT while the remainder reported hemodynamic data without a definition. The most common definitions of HIRRT were as follows: initiation or increase in vasopressor dose during therapy (9 articles), variability in MAP during treatment (8 articles), and blood pressure lower than a systolic and/or diastolic threshold (6 articles). Across all definitions, HIRRT differences for most studies trended in the same direction as clinical outcomes of mortality and renal recovery. For the HIRRT definition of “initiation or increase in vasopressor dose during therapy”, mortality rates trended in the same direction as HIRRT in all the studies that demonstrated a statistically significant difference in HIRRT.

Conclusions: This systematic review demonstrates significant heterogeneity in the definitions of HIRRT that have been used in prior RCTs. HIRRT differences trended in the same direction as clinical outcomes of mortality and renal recovery for most studies. This review examines the association between definitions of HIRRT and important clinical outcomes, including mortality and renal recovery, with the goal of paving the way towards a standardized definition of HIRRT for future research.