Early goal-directed therapy in patients with end-stage renal disease

Introduction

Patients with end-stage renal disease (ESRD) on dialysis are at increased risk for infection, yet few studies in sepsis focus on this population. The current study evaluates early goal-directed therapy (EGDT) for ESRD patients with severe sepsis and septic shock.

Methods

This is a post-hoc analysis of a randomized, prospective trial of patients presenting to an urban Emergency Department (ED) with severe sepsis and septic shock. Patients were enrolled in the study if they had two or more systemic inflammatory response syndrome criteria plus hypotension or lactic acidosis (> 4 mmol/l). Patients were randomized to either conventional care or EGDT that included resuscitation to goals of central venous pressure (CVP) between 8 and 10, mean arterial pressure (MAP) between 65 and 90, and central venous oximetry (ScvO₂) greater than 70%.

Results

Ten patients with ESRD were in the control group and eight in the treatment group. Baseline hemodynamic (heart rate [HR], MAP, CVP, ScvO₂) and severity of illness scores (APACHE, MODS, SAPS) were not different between groups. Seven out of 10 patients in the control group died compared with 1/8 in the EGDT group (P < 0.05). At 6 hours, the HR and CVP remained equal between groups, but a statistically significant rise in ScvO₂ and MAP was found between groups (P < 0.05). Additionally, the treatment group displayed a significant fall in lactate, APACHE, MODS, and SAPS scores (P < 0.05). The difference in ScvO2, lactate, and severity of illness remained significant at 72 hours (P < 0.05).

Conclusion

EGDT is both safe and efficacious for patients with ESRD, resulting in reduction of both morbidity and mortality. This improvement in outcome can be explained by eradication of global tissue hypoxia by aggressive resuscitation guided by goal-directed care. Although EGDT was performed for only 6 hours in the ED, the physiologic benefits persisted between groups at 72 hours.