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July 14, 2016

Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit.

Mazen Kherallah

Summarized by: 

What was the research question?

  • In adults patients with severe acute kidney injury, does early initiation of renal replacement therapy improve 60-day mortality compared to delayed renal replacement strategy?

How did they do it?

  • A multicenter randomized trial in 31 critical care units in France.

  • 620 patients with severe acute kidney injury (Kidney Disease: Improving Global Outcomes [KDIGO] classification, stage 3) who required mechanical ventilation, catecholamine infusion, or both and did not have a potentially life-threatening complication directly related to renal failure, were randomized to early renal-replacement therapy was started immediately after randomization (308 patients) or a delayed strategy of renal-replacement therapy where renal-replacement therapy was initiated if severe hyperkalemia, metabolic acidosis, pulmonary edema, blood urea nitrogen level higher than 112 mg per deciliter, or oliguria for more than 72 hours after randomization (311 patients).

  • The primary outcome was overall survival at day 60.

What did they find?

  • 60-day mortality was not significantly different in early RRT strategy compared to late RRT strategy (48.5% vs. 49.7%, P=0.79).

  • 49% of patients in the delayed-strategy group did not receive renal-replacement therapy.

  • The rate of catheter-related bloodstream infections was higher in the early-strategy group than in the delayed-strategy group (10% vs. 5%, P=0.03).

  • Diuresis, a marker of improved kidney function, occurred earlier in the delayed-strategy group (P<0.001).

What does it mean?

  • Among patients with severe acute kidney injury, early initiation of renal replacement therapy did not improve mortality and increased the rate of catheter-related bloodstream infection.

  • No need to start RRT unless the patient has acute indication.


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