Table 4.
Major randomized clinical trials investigating timing of dialysis initiation in acute kidney injury.
| Study | Population | Earlier Group | Later Group | Findings | Main Limitations |
|---|---|---|---|---|---|
| Effect of Early vs. Delayed Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients with Acute Kidney Injury (ELAIN), 2016 [82] | 231 critically ill patients with KDIGO stage 2 AKI and NGAL > 150 ng/mL | Within 8 h of diagnosis of stage 2 AKI | Within 12 h of developing stage 3 AKI or no initiation | Early KRT initiation was associated with reduced mortality over 90 days, more recovery of renal function, shorter duration of KRT, and hospital stay | One center; almost entirely surgical patients |
| Artificial Kidney Initiation in Kidney Injury (AKIKI), 2016 [83] | 620 critically ill patients with KDIGO stage 3 AKI | Immediately after randomization | If severe hyperkalemia, metabolic acidosis, pulmonary edema, BUN > 112 mg/dL, oliguria for >72 h | Early versus late KRT initiation did not affect mortality, but delayed initiation led to fewer patients on KRT, more KRT-free days, and fewer side effects | Only included patients with stage 3 AKI |
| Initiation of Dialysis Early Versus Delayed in the Intensive Care Unit (IDEAL-ICU), 2018 [85] | 477 patients with early-stage septic shock and RIFLE failure-stage AKI | Within 12 h after documentation of failure-stage AKI | Delay of 48 h after failure-stage AKI if renal recovery had not occurred | Early versus late KRT initiation did not affect overall mortality at 90 days | Used RIFLE criteria; 48 h relatively short time to allow for renal recovery |
| Standard versus Accelerated Initiation of Renal-Replacement Therapy in Acute Kidney Injury (STARRT-AKI), 2020 [86] | 3019 critically ill patients with KDIGO stage 2 or 3 AKI | Within 12 h of developing stage 2–3 AKI (“accelerated”) | If conventional indications developed or AKI persisted for >72 h (“standard”) | Accelerated versus standard KRT initiation did not affect overall mortality at 90 days, but more patients in accelerated group were still on KRT at 90 days and they had more adverse events | Allowed clinicians broad discretion regarding when to initiate KRT in standard group |
| AKIKI 2, 2021 [87] | 278 critically ill patients with KDIGO stage 3 AKI who had oliguria for >72 h or BUN > 112 mg/dL | At time of randomization (“delayed”) | If mandatory indication (noticeable hyperkalemia, metabolic acidosis, or pulmonary edema) developed or BUN reached 140 mg/dL (“more-delayed”) | Longer postponing of KRT initiation did not confer additional benefit and was associated with potential harm, including higher risk of death at 60 days | Used BUN levels as KRT initiation; somewhat different comparison as both groups were somewhat delayed |
Green indicates that early KRT showed benefit, blue indicates that late KRT showed benefit, and no color indicates no difference. KDIGO, Kidney Disease Improving Global Outcomes; NGAL, neutrophil gelatinase-associated lipocalin level (plasma); RIFLE, risk, injury, failure, loss, and end-stage kidney disease.