Interim results of the SHARF4 study: outcome of acute renal failure with different treatment modalities

Introduction

It is important for ICU physicians to predict the mortality of acute renal failure (ARF) in the first 24–48 hours. For this the SHARF II score at 0 and 48 hours has been developed [1]. This study will look at short-term and long-term morbidity and mortality with different modes of treatment in ARF.

Methods

A prospective multicentre randomised clinical trial. The target population was 1600 consecutive adult patients with ARF. Patients needing renal replacement therapy (RRT) were randomised to either slow extended daily dialysis (SLEDD) or continuous venovenous hemofiltration (CVVH). Randomisation was done according to the SHARF II0 score (< 30, 30–60 and > 60). Interim study endpoints were hospital morbidity and mortality.

Results

Interim analysis after 996 patients: age 66 ± 15.1 years, 62% male, SHARF II0 64.9 ± 32.6, SHARF II48 64.1 ± 32.2, SOFA0 8.4 ± 4.1, SOFA24 6.5 ± 5.1, APACHE II 23.5 ± 10.6. Diagnosis of ARF was medical in 67.9% and surgical in 32.1%. Cause of ARF was prerenal in 43.2%, and renal in 51.5%. Cause of renal ARF was ATN in 90.9%, and AGN in 5%. There were 13.8% of patients in SHARF category 1 (< 30), 24.8% in category 2 (30–60) and 52.2% in category 3 (> 60). The higher the SHARF score, the higher the APACHE II and SOFA score. RRT was needed in 59% of patients (2/3 randomised), 39% of them received continuous RRT while 61% received SLEDD. The main reason for choosing another treatment was hemodynamic instability (24%) or coagulation disturbance (25%). Outcome analysis (481 patients) showed a mortality of 56.5%, 2.9% developed ESRD, 10.2% had partial recovery and 30.4% had complete recovery of ARF. Mortality was 46% in conservative treatment versus 64% in CVVH and 68% in SLEDD. Figure 1 shows the mortality in the different SHARF categories. The ICU and hospital length of stay was higher in patients with RRT. Observed mortality was lower than expected in non-RRT but paralleled the expected in RRT.

Figure 1

Conclusion

The interim results of an ongoing study show that the SHARF score, with parameters at 0 and 48 hours, has good predictive value in estimating prognosis in ARF patients. Overall mortality was 56.5%, and 59% needed RRT. Mortality was the same regardless of RRT used. Major problems lay in recruiting centers using both techniques equally. The randomisation rate is lower than expected.