Femoral Access and Delivery of Continuous Renal Replacement Therapy Dose

Transcription

1 Originl Pper Received: June 4, 2015 Accepted: August 18, 2015 Published online: October 20, 2015 Femorl Access nd Delivery of Continuous Renl Replcement Therpy Dose Rinldo Bellomo, b John Mårtensson b, c Serigne Lo d Kirsi-Mij Kukonen Aln Css e Mrtin Gllgher d for the RENAL study investigtors nd the Austrlin nd New Zelnd Intensive Cre Clinicl Trils Group Austrlin nd New Zelnd Intensive Cre Reserch Centre (ANZIC-RC), Deprtment of Epidemiology nd Preventive Medicine, Monsh University, The Alfred Centre, Level 6, Melbourne, Vic., nd b Deprtment of Intensive Cre, Austin Hospitl, Heidelberg, Vic., Austrli; c Section of Anesthesi nd Intensive Cre Medicine, Deprtment of Physiology nd Phrmcology, Krolinsk Institutet, Soln, Sweden; d The George Institute for Globl Helth, University of Sydney, Level 13, Sydney, N.S.W., nd e Menzies School of Helth Reserch, Chrles Drwin University, Drwin, Winnellie, N.T., Austrli Key Words Dilysis Continuous renl replcement therpy Ctheters Femorl vein Intensive cre Abstrct Aims: The study ims to describe the use of dilysis ctheters in criticlly ill ptients treted with continuous renl replcement therpy (CRRT) nd to study the impct of femorl versus non-femorl ccess on CRRT dose. Methods: Sttisticl nlysis nd predictive modelling of dt from the Rndomized Evlution of Norml vs. Augmented Level renl replcement therpy tril. Results: The femorl vein ws the first ccess site in 937 (67%) of 1,399 ptients. These ptients hd higher Acute Physiology nd Chronic Helth Evlution nd Sequentil Orgn Filure Assessment scores (p = 0.009) nd lower ph (p < 0.001) but similr mortlity to ptients with non-femorl ccess (44 vs. 45%; p = 0.63). Lower body weight ws independently ssocited with femorl ccess plcement (OR 0.97, 95% CI ). Femorl ccess ws ssocited with 1.03% lower CRRT dose (p = 0.05), but 4.20% higher dose ws chieved with 13.5 Fr ctheters (p = 0.03). Conclusions: Femorl ccess ws preferred in lighter nd sicker ptients. Ctheter guge hd greter impct thn ctheter site in CRRT dose delivery. Video Journl Club Cppuccino with Cludio Ronco t S. Krger AG, Bsel Introduction The bility to mintin ptient homeostsis of wter, wste products, electrolytes nd cid-bse during continuous renl replcement therpy (CRRT) is dependent on CRRT circuit ptency over time [1]. The qulity of vsculr ccess influences the bility to chieve dequte nd relible blood flow through the circuit, mjor determinnt of circuit life spn. Ctheter dysfunction requiring A complete list of investigtors in the RENAL study is provided in the supplementry mteril (online suppl. item S1; for ll online suppl. mteril, see E-Mil krger@krger.com S. Krger AG, Bsel /15/ $39.50/0 Prof. Rinldo Bellomo Deprtment of Intensive Cre, Austin Helth 145 Studley Rod Heidelberg, VIC 3084 (Austrli) E-Mil ustin.org.u

2 ctheter replcement nd/or cusing circuit filure occurs in pproximtely 10% of ptients treted with CRRT [2, 3]. Such circuit filures induce interruptions in tretment, which decrese the delivered CRRT dose nd uremic control [4]. Moreover, they significntly increse nursing worklod nd tretment costs [5]. Thus, both choice of optiml insertion site nd ctheter chrcteristics re importnt to delivering optiml therpy. There is uncertinty regrding the optiml site of ctheter insertion for CRRT in criticlly ill ptients. Femorl vein ctheteriztion my be fster nd esier thn jugulr vein ctheteriztion [6] but my impede mobiliztion [7]. Thus, recent guidelines fvor the right jugulr vein in preference to femorl veins [8]. These recommendtions re, however, not supported by robust evidence. Furthermore, the impct of ctheter brnd, guge nd length on the delivery of CRRT hs only been investigted in smll studies nd no robust evidence exists to guide choice of ctheter. The Rndomized Evlution of Norml vs. Augmented Level of Replcement Therpy (RENAL) study collected detiled informtion on dilysis ctheter chrcteristics, site of ctheter insertion nd circuit nticogultion during CRRT nd therefore offers unique opportunity to explore the reltionship between these fctors nd delivered CRRT dose [9 11]. Accordingly, we imed to describe the use of temporry dilysis ctheters in intensive cre unit (ICU) ptients treted with CRRT. In prticulr, we sought to identify fctors ssocited with choosing the femorl vein s first site of ctheter insertion nd to explore the ssocition of first insertion site (femorl vs. non-femorl) nd different ctheter chrcteristics with delivered CRRT dose during the first full dy of tretment. Mterils nd Methods Study Protocol The RENAL study ws prospective, multicenter, rndomized, controlled tril compring higher (40 ml/kg/h) versus lower (25 ml/kg/h) CRRT dose in 1,508 criticlly ill ptients. The Humn Reserch Ethics Committees of the University of Sydney nd of ll prticipting institutions pproved the study. Written informed consent ws obtined from ptients or next of kin. Adult ptients ( 18 yers) with severe AKI requiring cute RRT were included if they met t lest one of the following criteri: oliguri (urine output <100 ml during 6 h not responding to fluid resuscittion), hyperklemi (serum potssium >6.5 mmol/l), severe cidosis (ph <7.2), serum ure level >25 mmol/l, serum cretinine level >300 μmol/l or the presence of cliniclly significnt orgn edem. Ptients with previous RRT during the sme hospitliztion or those with end-stge renl filure requiring chronic dilysis were excluded. A detiled study protocol is found in the ppendix of the originl study [11]. The primry end point ws 90-dy mortlity. Secondry end points included RRT-free dys, mechnicl ventiltion-free dys, ICU-free dys nd hospitl-free dys t 90-dy follow-up. The site of dilysis ctheter insertion, ctheter choice nd mode of circuit nticogultion were determined by the treting physicin. For the purpose of the present study, the delivered CRRT dose (s percentge of prescribed dose) during the first complete 24-hour dy ws recorded. Sttisticl Anlysis Dt ws nlyzed by using SAS softwre version 9.1. Continuous vribles were expressed s men (SD) nd ctegoricl vribles s numbers (%). The Student t test or the Mnn Whitney test ws used to compre continuous vribles. The χ 2 test or the Fisher s exct test ws used to compre ctegoricl vribles. Multivrite logistic regression nlysis ws used to study the ssocition of hving the femorl vein s first site of ctheter insertion. Bseline vribles were considered nd were included in the multivrite model if they were sttisticlly significnt t p vlue <0.20 in the univrite nlysis. The ssocition between using femorl ctheter (vs. non-femorl ctheter) nd CRRT dose during the first complete 24 h ws ssessed by multivrite liner regression nlysis. The following potentil confounders were considered: tretment group, bseline chrcteristics, illness severity, ctheter guge, ctheter length, ctheter brnd, CRRT mchine nd nticogultion mode. Covrites were included in the multivrite model if they were sttisticlly significnt t p vlue <0.20 in the univrite nlysis. In the finl nlyses, 2-sided p vlue <0.05 ws considered sttisticlly significnt. Results First Site of Ctheter Insertion Of the 1,508 rndomized ptients in the RENAL tril, dt on first dilysis ctheter insertion site ws vilble for 1,399 (93%) ptients. In 937 (67%) of these 1,399 ptients the femorl vein ws chosen s the first site of dilysis ctheter insertion ( fig. 1 ). The right femorl vein ws preferred over the left. Jugulr ccess ws used in 351 (25%) ptients nd subclvin ccess ws chosen in 111 (8%) ptients. Fctors Associted with Femorl Vein Ctheteriztion Demogrphics, dmission dignosis, time from ICU dmission to rndomiztion, tretment group, bseline biochemistry nd outcomes for ptients with femorl nd non-femorl vein s first site of dilysis ctheter insertion re detiled in tble 1. Ptients receiving femorl ccess weighed on n verge 3.8 kg less thn ptients receiving non-femorl ccess (p < 0.001; tble 1 ) nd hd higher Acute Physiology nd Chronic Helth Evlution (APACHE) III scores, crdiovsculr Sequentil Orgn Filure Assessment scores, hemoglobin levels nd chlo- 12 Bellomo et l.

3 Tble 1. Chrcteristics of ptients ccording to first site of ctheter insertion Chrcteristic Femorl (n = 937) Non-femorl (n = 462) p vlues Age, yers 64.3± ± Mle sex 593 (63.3) 307 (66.5) 0.3 APACHE III score (25.7) (25.4) 0.02 Time from ICU dmission to rndomiztion, h 46.1± ± Rndomized to high CRRT intensity 456 (48.7) 236 (51.1) 0.40 Estimted glomerulr filtrtion rte, ml/min 57.5± ± Body weight, kg 79.5± ±13.4 <0.001 Mechnicl ventiltion 681 (72.7) 356 (77.1) 0.08 Severe sepsis t bseline 473 (50.5) 213 (46.1) 0.1 Non-opertive dmission dignosis 695 (74.2) 303 (65.6) 0.6 Opertive dmission dignosis 242 (25.8) 159 (34.4) 0.6 Severe cidemi (ph <7.2) 361 (38.5) 132 (28.6) <0.001 Severe orgn edem 421 (44.9) 200 (43.3) 0.6 Crdiovsculr SOFA score 2.9 (1.5) 2.7 (1.6) INR, % 1.8± ± APTT, s 45.8± ± Hemoglobin, g/l 100.7± ± Pltelet count, 10 9 /l 183.6± ± Sodium, mmol/l 137.3± ± Chloride, mmol/l 105.0± ± CRRT dose during the first complete 24 h, ml/kg/h 27.5± ± Delivered/prescribed CRRT dose during the first complete 24 h, % 85.4± ± Durtion first ctheter/totl CRRT time, % 96.6± ± Deth in ICU 328 (35.0) 151 (32.7) 0.4 Deth t dy (43.8) 208 (45.1) 0.6 Vribles re given s men ± SD or s numbers (percentge). APTT = Activted prtil thromboplstin time; INR = interntionl normlized rtio. ride levels. CRRT ws initited 46.5 h fter ICU dmission in ptients with femorl ccess nd fter 62.5 h in ptients with non-femorl ccess (p = 0.02). The first femorl ccess ws used during 96.6% of the totl CRRT time nd the first non-femorl ccess ws used during 94.5% of the totl CRRT time (p = 0.58; tble 1 ). Overll, 410 (44%) ptients with femorl dilysis ctheter s first ccess hd died t 90 dys fter rndomiztion compred with 208 (45%) non-femorl ccess ptients ( tble 1 ). Severl fctors were ssocited with greter likelihood of the use of femorl vein s the first site of ctheter insertion on univrite logistic regression nlysis. On multivrite logistic regression nlysis, however, only body weight (OR 0.97 for ech kg increse, 95% CI ), sodium levels (OR 0.93 for ech mmol increse, 95% CI ) nd chloride levels (OR 1.08 for ech mmol increse, 95% CI ) were independently ssocited with choosing the femorl vein s the first site of ccess ( tble 2 ). Right femorl vein Left femorl vein Right jugulr vein Left jugulr vein Left subclvin vein Right subclvin vein First site of dilysis ctheter insertion (%) Fig. 1. Site of first temporry dilysis ctheter insertion in the RENAL tril (n = 1,399). Femorl Access nd Delivery of CRRT Dose 13

4 Tble 2. Univrite nd multivrite logistic regression nlysis of femorl vein s first site of ctheter insertion Vribles Univrite nlysis Multivrite nlysis OR (95% CI) p vlues OR (95% CI) p vlues Body weight, kg ( ) < ( ) <0.001 Sodium, mmol/l ( ) ( ) <0.001 Chloride, mmol/l ( ) ( ) <0.001 Adjusted for bseline chrcteristics with p < 0.20 in the univrite nlyses. Only vribles with p < 0.05 in the multivrite nlysis re shown. <15 cm p < Femorl (n = 899) Non-femorl (n = 448) 11.5 Fr 12 Fr p = Femorl (n = 911) Non-femorl (n = 448) cm 12.5 Fr cm 13 Fr 13.5 Fr 24 cm 14 Fr Ptients (%) b Ptients (%) Nigr Heprin Arrow Gmcth None Edwrds Other p < Femorl (n = 926) Non-femorl (n = 451) Other p > 0.05 Femorl (n = 846) Non-femorl (n = 425) c Ptients (%) d Ptients (%) Fig. 2. Length ( ), guge ( b ) nd brnd ( c ) of dilysis ctheter s well s circuit nticogultion ( d ) during CRRT in the RENAL tril ccording to first site of ctheter insertion. Ctheter Chrcteristics nd Circuit Anticogultion Longer ctheters were generlly used for femorl ccess, wheres shorter ctheters tended to be inserted in nonfemorl sites ( fig. 2 ). A 13.5-Fr ctheter ws most commonly chosen for both femorl (68%) nd non-femorl ccess (59%; fig. 2 b). Longer nd greter guge Nigr (Brd, Murry Hill, N.J., USA) ctheters were minly used in the femorl (62%) nd non-femorl (53%) group ( fig. 2 c). Informtion on circuit nticogultion ws vilble for 1,271 (91%) ptients. Heprin ws used in 487 (58%) 14 Bellomo et l.

5 Tble 3. Multivrite liner regression showing the ssocition with delivered CRRT dose (s % of prescribed dose) during the first complete 24-hour period Vrible Coefficient, ±SE p vlues Femorl ctheter (vs. non-femorl) 1.03± French ctheter (vs. other guges) 4.20± or 24-cm ctheter (vs. other lengths) 1.88± Rndomized to higher CRRT intensity 26.32±1.27 <0.001 Adjusted for ge, sex, APACHE III score, body weight, oliguri, hyperklemi, cidemi, oedem, ure, cretinine, ctheter brnd, CRRT mchine use nd mode of circuit nticogultion. of 846 of ptients in the femorl group nd 269 (63%) of 425 ptients in the non-femorl group. CRRT ws delivered without circuit nticogultion in high proportion of ptients with femorl (41%) nd non-femorl (36%) ctheters (p = 0.50; fig. 2 d). Fctors Associted with Delivered CRRT Dose during the First 24 h A totl of 456 (48.7%) ptients with femorl ccess were rndomized to high intensity therpy (40 ml/kg/h) compred to 236 (51.1%) ptients with non-femorl ctheter (p = 0.40). On n verge, CRRT intensity during the first complete 24 h ws 27.5 ml/kg/h in the femorl group nd 26.2 ml/kg/h in the non-femorl group (p = 0.01). On n verge, 85.4 nd 81.9% of the prescribed dose (p = 0.002), respectively, ws chieved during this period ( tble 1 ). On multivrite liner regression, djusting for bseline chrcteristics, tretment group, ctheter chrcteristics, CRRT mchine nd mode of circuit nticogultion, the use of femorl ctheter ws ssocited with 1.03% lower CRRT dose (p = 0.05) during the first 24 h thn when non-femorl ctheter ws used ( tble 3 ). In contrst, 4.20% higher CRRT dose ws chieved with 13.5 Fr guge ctheters thn with other ctheter guges (p = 0.03). Finlly, being rndomized to higher intensity CRRT ws independently ssocited with 26.32% lower CRRT dose thn being llocted to lower intensity CRRT. Discussion Key Findings We nlyzed the use of temporry dilysis ctheters, the choice of insertion site, the ctheter guge nd their impct on CRRT dose in criticlly ill ptients enrolled in the RENAL tril. We found tht the femorl vein ws used s the first site of dilysis ctheter insertion in two thirds of ptients nd ws preferentilly chosen in ptients with lower body weight nd in sicker ptients. Using femorl vein for vsculr ccess hd limited impct on the delivered erly CRRT dose during the first 24 h. In contrst, ctheter guge ws more importnt determinnt of delivered CRRT dose during this time frme. Reltionship to Previous Studies Previous studies investigting the impct of vsculr ccess site on delivered RRT dose hve reported inconsistent results. Hryszko et l. [12] found n independent 5-fold higher risk of ctheter dysfunction, defined s inbility to mintin blood flow of t lest 150 ml/h, with femorl s compred to internl jugulr ctheters. In tht study, however, 75% of ptients were fully mobile, nd tretment ws with intermittent hemodilysis. Lingos et l. [13] explored dilysis performnce during >400 intermittent hemodilysis sessions in 81 ptients with cute renl filure. Use of femorl ccess, s compred to non-femorl ccess, ws independently ssocited with lower ure reduction rtio with intermittent hemodilysis. Of note, however, the femorl ctheters used in this study were short, mesuring only 16.5 or 19.5 cm. To optimize blood flow nd CRRT dose nd to void recircultion, it is importnt tht the ctheter tip is plced in lrge vein (externl ilic nd close of inferior ven cv) or in the right trium [5, 14, 15]. Therefore, it is recommended tht 24-cm ctheters be used in the femorl position, nd tht cm ctheters be used for right jugulr cnnultions [16]. In 11 of the 12 centers involved in the French Cthedi study, 16-cm ctheters were used in the jugulr nd 25-cm ctheters in the femorl position [17]. Similrly, 24-cm ctheters were frequently used for femorl (48%) nd 15- to 16-cm ctheters were frequently used for jugulr or subclvin ccess (50%) in the RENAL study ptients. The Cthedi study showed higher rte of ctheterrelted infections with femorl ccess in ptients with Femorl Access nd Delivery of CRRT Dose 15

6 body mss index >28.4 kg/m 2 [17]. Furthermore, the incresed ctheter-relted infections risk in hevier ptients (>90 kg) with femorl dilysis ctheters ws recently confirmed in n observtionl study involving 458 ptients [18]. It is therefore not surprising tht RENAL study ptients receiving right or left femorl ctheteriztion [19] hd lower body weight thn ptients receiving non-femorl ctheteriztion. Implictions of Study Findings Our study suggest tht clinicins perceive the femorl vein to be useful potentil first choice when rpid nd sfe ccess is needed nd in ptients with multilumen centrl venous ctheter in the right jugulr vein [6]. Our results reflect this preference with sicker ptients (more severe cidemi, higher APACHE III nd crdiovsculr Sequentil Orgn Filure Assessment score nd fster initition of CRRT fter ICU dmission) being more likely to hve their first CRRT ctheter inserted in the femorl vein. This, in turn, my reflect the fct tht centrl venous ctheter is often inserted before temporry dilysis ctheter in hemodynmiclly unstble ptients. Under such circumstnces, the femorl route my be the only vilble option. Finlly, we found tht femorl vein is preferred in ptients with lower body weight. Although we did not ssess body hbitus, this finding my reflect the fct tht femorl vein cnnultion my be techniclly difficult nd is therefore voided in obese ptients. In the univrite comprison, the delivered CRRT dose (s percentge of the prescribed dose) ws 3.5% higher through femorl ccess thn through non-femorl ccess ( tble 1 ). A femorl ccess ws, however, ssocited with 1.03% lower CRRT delivery in the multivrite liner regression nlysis. The fct tht higher proportion of ptients with femorl ccess were cnnulted with lrge-guge 13.5 Fr ctheters s compred to ptients with non-femorl ccess (67.5 vs. 59.2%, p = 0.009) likely explins the reversed result in the multivrite djusted nlysis. In fct, fter djusting for severl potentilly importnt confounders of the reltionship between ccess site nd dose, lrger ctheter guge (13.5 Fr) ws independently ssocited with delivery of higher (4.2%) CRRT dose wheres the bility to chieve the prescribed dose ws, s could be expected, impired in ptients llocted to higher intensity CRRT. These findings need to interpreted in the light of the originl RENAL tril results. In the RENAL tril, the high-intensity group received 50% higher CRRT dose thn the low-intensity group. Despite this difference in dose, 90-dy mortlity ws similr in both the groups. Our results therefore suggest tht insertion of 13.5 Fr guge CRRT ctheters in the femorl vein of very sick criticlly ill ptients hve no cliniclly importnt negtive impct on erly CRRT delivery. This is n importnt finding since femorl ctheter insertion is sfer nd esier pproch for less experienced, junior doctors thn cnnultion of internl jugulr or subclvin veins. Strengths nd Limittions This study hs importnt strengths. All study dt, including highly detiled informtion on ctheter chrcteristics, insertion site nd CRRT dose were prospectively collected. In ddition, the lrge study size enbled djustment for numerous fctors such s ptient chrcteristics, ctheter fetures nd mode of nticogultion, which my potentilly ffect CRRT delivery. With such djustments, importnt prcticl observtions emerged, which cn be used to inform clinicl prctice. This study hs limittions. Choice of ctheter insertion site nd guge were not rndomized. However, our study provides the lrgest description of CRRT ctheter chrcteristics, guge nd site of insertion to dte nd detiled informtion to djust for mny key erly confounders. No informtion on ctheter tip plcement ws vilble. However, since longer ctheters were used in the femorl position nd since non-femorl ctheters were minly inserted in the right jugulr vein, it is likely tht most of the ctheters were positioned correctly. Our study does not provide informtion on the impct of insertion site or guge on CRRT delivery beyond the first complete 24 h. This ws, however, our intention since determinnts of CRRT dose unrelted to ccess, such s interruptions for investigtions, opertions nd mortlity would crete strong competing risk-relted confounding effect, given tht femorl ctheters were inserted in sicker ptients. By restricting the nlysis to the first complete 24 h of CRRT, we imed to diminish the impct of such confounders. Conclusions The femorl vein ws used s the first site of dilysis ctheter insertion in most ptients within the RENAL tril, especilly in lighter nd sicker ptients. Although such use of femorl ccess ws significntly ssocited with lower CRRT dose, the impct on dose ws limited. However, using lrger guge ctheter ws independently s- 16 Bellomo et l.

7 socited with the bility to deliver higher CRRT dose during the first 24 h. This informtion provides cliniclly relevnt informtion to ssist clinicins in their choice of preferred ccess site nd ctheter guge for the delivery of CRRT in criticlly ill ptients. Acknowledgments Contributions Reserch ide nd study design: R.B., A.C., M.G.; dt nlysis/interprettion: J.M., R.B., S.L.; sttisticl nlysis: S.L.; supervision nd mentorship: R.B.; drfting of mnuscript: J.M., K.M.K., R.B. Ech uthor contributed importnt intellectul content during mnuscript revision nd ccepts ccountbility for the overll work by ensuring tht questions pertining to the ccurcy or integrity of ny portion of the work re ppropritely investigted nd resolved. R.B. nd M.G. tke responsibility tht this study hs been reported honestly, ccurtely nd trnsprently; tht no importnt spects of the study hve been omitted nd tht ny discrepncies from the study s plnned hve been explined. Support nd Finncil Disclosure Declrtion This study ws supported by grnts from the Ntionl Helth nd Medicl Reserch Council (NHMRC) of Austrli (grnt ) nd Helth Reserch Council (HRC) of New Zelnd (grnt ). The study sponsors hd no role in study design; collection, nlysis, nd interprettion of dt; writing the report; or the decision to submit the report for publiction. Professor A. Css received funding from the Austrlin Ntionl Helth nd Medicl Reserch Council nd grnt support from Roche nd Gmbro. Professor R. Bellomo received consulting fees s n dvisor for Gmbro; nd consulted for Gmbro, Biosite, Abbott nd Philipps. Dr. M. Gllgher received honorri/speking fees from Roche. Dr. J. Mårtensson received trvel support to present reserch results t scientific meetings from Gmbro nd funding from Krolinsk Institutet. The remining uthors hve not disclosed ny potentil conflicts of interest. The George Institute hs received reserch funding from Servier, Novrtis, Eisi, Merck, Shrp & Dohme, Pfizer Austrli, Fresenius Kbi Deutschlnd GmbH nd Snofi Aventis. The RENAL Replcement Therpy Study is collbortion of the Austrlin nd New Zelnd Intensive Cre Society Clinicl Trils Group (ANZICS CTG) nd the George Institute for Interntionl Helth. References 1 Jonnidis M, Oudemns-vn Strten HM: Clinicl review: ptency of the circuit in continuous renl replcement therpy. Crit Cre 2007; 11: Prienti JJ, Mégrbne B, Fischer MO, Lutrette A, Gzui N, Mrin N, et l: Ctheter dysfunction nd dilysis performnce ccording to vsculr ccess mong 736 criticlly ill dults requiring renl replcement therpy: rndomized controlled study. Crit Cre Med 2010; 38: Beitlnd S, Sunde K, Moen H, Os I: Vribility in uremic control during continuous venovenous hemodifiltrtion in trum ptients. Crit Cre Res Prct 2012; 2012: Fely N, Bldwin I, Bellomo R: The effect of circuit down-time on uremic control during continuous veno-venous hemofiltrtion. Crit Cre Resusc 2002; 4: Morgn D, Ho K, Murry C, Dvies H, Louw J: A rndomized tril of ctheters of different lengths to chieve right trium versus superior ven cv plcement for continuous renl replcement therpy. Am J Kidney Dis 2012; 60: Dugué AE, Levesque SP, Fischer MO, Souweine B, Mir JP, Megrbne B, et l: Vsculr ccess sites for cute renl replcement in intensive cre units. Clin J Am Soc Nephrol 2012; 7: Kim IB, Fely N, Bldwin I, Bellomo R: Insertion side, body position nd circuit life during continuous renl replcement therpy with femorl vein ccess. Blood Purif 2011; 31: Lmeire N, Kellum JA: Contrst-induced cute kidney injury nd renl support for cute kidney injury: KDIGO summry (prt 2). Crit Cre 2013; 17: Finfer S, Css A, Gllgher M, Lee J, Su S, Bellomo R: The RENAL (rndomised evlution of norml vs. ugmented level of replcement therpy) study: sttisticl nlysis pln. Crit Cre Resusc 2009; 11: Bellomo R, Css A, Cole L, Finfer S, Gllgher M, Goldsmith D, et l: Design nd chllenges of the rndomized evlution of norml versus ugmented level replcement therpy (RENAL) tril: high-dose versus stndrddose hemofiltrtion in cute renl filure. Blood Purif 2008; 26: Bellomo R, Css A, Cole L, Finfer S, Gllgher M, Lo S, et l: Intensity of continuous renlreplcement therpy in criticlly ill ptients. N Engl J Med 2009; 361: Hryszko T, Brzosko S, Mzersk M, Mlyszko J, Mysliwiec M: Risk fctors of nontunneled noncuffed hemodilysis ctheter mlfunction. A prospective study. Nephron Clin Prct 2004; 96:c43 c Lingos O, Ro M, Ruthzer R, Blkrishnn VS, Modi G, Pereir BJ, et l: Fctors ssocited with ure reduction rtio in cute renl filure. Artif Orgns 2004; 28: Leblnc M, Fedk S, Mokris G, Pgnini EP: Blood recircultion in temporry centrl ctheters for cute hemodilysis. Clin Nephrol 1996; 45: Little MA, Conlon PJ, Wlshe JJ: Access recircultion in temporry hemodilysis ctheters s mesured by the sline dilution technique. Am J Kidney Dis 2000; 36: Mrozek N, Lutrette A, Timsit JF, Souweine B: How to del with dilysis ctheters in the ICU setting. Ann Intensive Cre 2012; 2: Prienti JJ, Thirion M, Mégrbne B, Souweine B, Ouchikhe A, Polito A, et l: Femorl vs jugulr venous ctheteriztion nd risk of nosocomil events in dults requiring cute renl replcement therpy: rndomized controlled tril. JAMA 2008; 299: Chu HR, Schneider AG, Sherry NL, Lotfy N, Chn MJ, Gltieri J, et l: Initil nd extended use of femorl versus nonfemorl double-lumen vsculr ctheters nd ctheter-relted infection during continuous renl replcement therpy. Am J Kidney Dis 2014; 64: Crosswell A, Brin MJ, Roodenburg O: Vsculr ccess site influences circuit life in continuous renl replcement therpy. Crit Cre Resusc 2014; 16: Femorl Access nd Delivery of CRRT Dose 17