article162

AKIKI

"Timing of Renal Replacement Therapy in Acute Kidney Injury". The New England Journal of Medicine. 2016.

Clinical Question

In critically ill patients with severe acute kidney injury, does early initiation of renal replacement therapy improve survival compared to delayed initiation?

Bottom Line

In critically ill patients with severe acute kidney injury, early versus delayed initiation of renal replacement therapy showed no significant difference in mortality.

Major Points

Guidelines

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.

Design

- 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

Population

- 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

Interventions

- 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

Outcomes

- 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)

Criticisms

- 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.

Funding

Funded by the French Ministry of Health.