Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury.

STARRT-AKI, Investigators; Bagshaw, Sean M; Wald, Ron; Adhikari, Neill K J; Bellomo, Rinaldo; Da Costa, Bruno R.; Dreyfuss, Didier; Du, Bin; Gallagher, Martin P; Gaudry, Stéphane; Hoste, Eric A; Lamontagne, François; Joannidis, Michael; Landoni, Giovanni; Liu, Kathleen D; McAuley, Daniel F; McGuinness, Shay P; Neyra, Javier A; Nichol, Alistair D; Ostermann, Marlies; ... (2020). Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury. New England journal of medicine NEJM, 383(3), pp. 240-251. Massachusetts Medical Society MMS 10.1056/NEJMoa2000741

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BACKGROUND

Acute kidney injury is common in critically ill patients, many of whom receive renal-replacement therapy. However, the most effective timing for the initiation of such therapy remains uncertain.

METHODS

We conducted a multinational, randomized, controlled trial involving critically ill patients with severe acute kidney injury. Patients were randomly assigned to receive an accelerated strategy of renal-replacement therapy (in which therapy was initiated within 12 hours after the patient had met eligibility criteria) or a standard strategy (in which renal-replacement therapy was discouraged unless conventional indications developed or acute kidney injury persisted for >72 hours). The primary outcome was death from any cause at 90 days.

RESULTS

Of the 3019 patients who had undergone randomization, 2927 (97.0%) were included in the modified intention-to-treat analysis (1465 in the accelerated-strategy group and 1462 in the standard-strategy group). Of these patients, renal-replacement therapy was performed in 1418 (96.8%) in the accelerated-strategy group and in 903 (61.8%) in the standard-strategy group. At 90 days, death had occurred in 643 patients (43.9%) in the accelerated-strategy group and in 639 (43.7%) in the standard-strategy group (relative risk, 1.00; 95% confidence interval [CI], 0.93 to 1.09; P = 0.92). Among survivors at 90 days, continued dependence on renal-replacement therapy was confirmed in 85 of 814 patients (10.4%) in the accelerated-strategy group and in 49 of 815 patients (6.0%) in the standard-strategy group (relative risk, 1.74; 95% CI, 1.24 to 2.43). Adverse events occurred in 346 of 1503 patients (23.0%) in the accelerated-strategy group and in 245 of 1489 patients (16.5%) in the standard-strategy group (P<0.001).

CONCLUSIONS

Among critically ill patients with acute kidney injury, an accelerated renal-replacement strategy was not associated with a lower risk of death at 90 days than a standard strategy. (Funded by the Canadian Institutes of Health Research and others; STARRT-AKI ClinicalTrials.gov number, NCT02568722.).

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