"Timing of Renal Replacement Therapy in Acute Kidney Injury". The New England Journal of Medicine. 2016.
Links to original sources: Wiki Journal Post Full Journal Article
In critically ill patients with severe acute kidney injury, does early initiation of renal replacement therapy improve survival compared to delayed initiation?
In critically ill patients with severe acute kidney injury, early versus delayed initiation of renal replacement therapy showed no significant difference in mortality.
The timing of renal replacement therapy (RRT) initiation in critically ill patients with acute kidney injury (AKI) is controversial. The Artificial Kidney Initiation in Kidney Injury (AKIKI) trial tested whether early initiation of RRT in patients with stage 3 AKI who required mechanical ventilation, catecholamine infusion, or both would reduce mortality compared to a delayed strategy. The early strategy started RRT immediately after randomization, while the delayed strategy initiated RRT only if specific life-threatening criteria were met. At 60 days, there was no significant difference in mortality between the two groups.
The optimal timing of RRT initiation in critically ill patients with AKI remains uncertain, as current guidelines have heterogeneous criteria for RRT initiation and highlight the need for further research.
- Multicenter, randomized, open-label, two-group trial - N=620 patients - Early-strategy group (n=312) - Delayed-strategy group (n=308) - Setting: 31 intensive care units in France - Enrollment: September 2013 to January 2016 - Primary outcome: Overall survival at day 60 - Randomized within 5 hours after reaching stage 3 AKI
- Adults (≥18 years) admitted to ICU with severe AKI (KDIGO stage 3) - Required mechanical ventilation, catecholamine infusion, or both - Excluded if immediate life-threatening complications from renal failure were present
- Early-strategy: Initiate RRT immediately after randomization - Delayed-strategy: Initiate RRT only upon developing severe hyperkalemia, metabolic acidosis, pulmonary edema, BUN >112 mg/dL, or oliguria persisting more than 72 hours post-randomization
- Overall mortality at day 60: 48.5% early-strategy vs. 49.7% delayed-strategy (P=0.79) - 49% in delayed-strategy group did not receive RRT - Higher rate of catheter-related bloodstream infections in the early-strategy group (10% vs. 5%; P=0.03) - Faster recovery of renal function in the delayed-strategy group (P<0.001)
- Study may be underpowered to detect small differences in mortality. - Majority of patients received intermittent hemodialysis, limiting generalizability. - Patients had advanced AKI, thus results may not apply to all KDIGO stages of AKI.
Funded by the French Ministry of Health.
ClinicalTrials.gov number, NCT01932190.