Written by Mary Marschner
Spoon Feed
Early vs. delayed renal replacement therapy (RRT) showed no mortality difference in ICU patients with KDIGO stage 3 acute kidney injury (AKI).
In the ICU, watch for AEIOUs
Critically ill patients in the ICU have a high mortality rate and often have severe AKI. Prior to the AKIKI trial, it was unclear whether there was benefit to initiating RRT in these patients with severe AKI but without a specific indication: AEIOU- Acidosis, Electrolytes (e.g. hyperkalemia), Ingestions (e.g. salicylate), Overload (e.g. pulmonary edema with hypoxemia), Uremia). In fact, the observational studies prior to this RCT suggested a mortality benefit from early-initiation RRT.
The AKIKI trial, a multicenter randomized controlled study, evaluated early versus delayed initiation of renal replacement therapy (RRT) in critically ill patients with severe AKI (KDIGO stage 3) requiring mechanical ventilation or vasopressors. Early RRT was initiated immediately post-randomization; delayed RRT was initiated upon specific criteria (e.g., severe hyperkalemia, metabolic acidosis, pulmonary edema, BUN >112 mg/dL, or oliguria >72 hours). Among 620 patients, 60-day mortality was similar between groups: 48.5% (early) vs. 49.7% (delayed); P=0.79. Notably, 49% in the delayed group avoided RRT, and catheter-related bloodstream infections were lower (5% vs. 10%, P=0.03). These findings suggest that a delayed RRT strategy may reduce unnecessary interventions without increasing mortality.
This was a very well-done study, and I think it’s also important to note that despite patients with early-initiation RRT having a higher incidence of bloodstream infections, it surprisingly didn’t create a difference in observed mortality for the sixty days of the clinical trial.
How does this change my practice?
This study supports the guideline recommendation to delay RRT unless there is a critical indication. Although it may postpone my nephrology consult for 12 to 24 hours, this trial gives me confidence to more patiently monitor my patients for renal recovery before committing them to central line placement and dialysis.
Source
Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit. N Engl J Med. 2016 Jul 14;375(2):122-33. doi: 10.1056/NEJMoa1603017. Epub 2016 May 15. PMID: 27181456
