Table 2 |.
Timing for RRT in S-AKI
| Trial | Setting | Percentage of sepsis | Modality of RRT | Timing of RRT initiation | Outcome | |
|---|---|---|---|---|---|---|
| Early strategy | Delayed strategy | |||||
| Gaudry et al.147 (AKIKI) | Adults, ICU patients with AKI (multicenter) | 80% | IHD/CRRT | Median time 2 h (IQR: 1–3 h) after randomization or 4.3 h (IQR: 2.7–5.9 h) after documented KDIGO stage 3 AKI, N = 311 | Median time 57 h (IQR: 25–83 h) after randomization, N = 308 (51% received RRT) | No difference in 60-day mortality (48.5% vs. 49.7%), post hoc analysis in patients with septic shock (56%) showed similar results, more patients with CRBSI and hypophosphatemia in early group, adequate diuresis with no need for RRT were observed earlier in delayed group. |
| Zarbock et al.148 (ELAIN) | Adults, ICU patients, 47% with cardiac surgery (single center) | 21% | CVVHDF | Median time 6 h (IQR: 4–7 h) after documented KDIGO stage 2 AKI, N = 112 | Median time 25.5 h (IQR: 18.8–40.3 h) after documented KDIGO stage 2 AKI (within 12 h after KDIGO stage 3 AKI), N = 119 (91% received RRT) | Significantly lower 90-day mortality in early group (39.3% vs. 54.7%), no difference in renal recovery at 90 days, 95% of study population were surgical patients and small number of patients with sepsis. |
| In follow-up analysis found significantly reduced rate of MAKE365 (64.9% vs. 89.1%) and 1-year mortality (50.2% vs. 69.8%) in early group. | ||||||
| Barbar et al.149 (IDEAL-ICU) | Adults, patients with septic shock and severe AKI (multicenter) | 100% | IHD/CRRT | Median time 7.6 h (IQR: 4.4–11.5 h) after RIFLE-F, N = 246 | Median time 51.5 h (IQR: 34.6–59.5 h) after documented AKI or meet emergency RRT criteria (K >6.5 mmol/l, pH < 7.15, fluid overload), N = 242 (51% received RRT) | No difference in 90-day mortality (58% vs. 54%), more days of RRT and less RRT-free days in early group, more patients with hyperkalemia in delayed group, similar fluid balance, 29% of patients in delayed group had spontaneous recovery. |
| STARRT-AKI () | Adults, ICU patients with severe AKI (RIFLE-I, oliguria, pNGAL $400 ng/ml (multicenter) | N/A | IHD/SLED/CRRT | “Accelerated” initiation: RRT will be initiated within 12 h of fulfilling eligibility | “Standard” initiation: participants will be monitored over 7 days to identify indications for RRT (K ≥6.0 mmol/l, bicarbonate ≤10 mmol/l, PaO2/FiO2 <200 and bilateral infiltrates on CXR, persistent AKI >72 h after eligibility) | N/A |
AKIKI, Artificial Kidney Initiation in Kidney Injury trial; CRBSI, catheter-related bloodstream infection; CRRT, continuous renal replacement therapy; CVVHDF, continuous venovenous hemodiafiltration; CXR, chest x-ray; ELAIN, Early Versus Late Initiation of Renal Replacement Therapy in Critically Ill Patients With Acute Kidney Injury trial; ICU, intensive care unit; IDEAL-ICU, Initiation of Dialysis Early Versus Delayed in the Intensive Care Unit trial; IHD, intermittent hemodialysis; IQR, interquartile range; KDIGO, Kidney Disease: Improving Global Outcomes; MAKE365, major adverse kidney events by 365 days; N/A, not applicable; pNGAL, plasma neutrophil gelatinase-associated lipocalin; RIFLE, Risk, Injury, Failure, Loss of Kidney Function, End-Stage Kidney Disease classification; RRT, renal replacement therapy; S-AKI, sepsis-associated acute kidney injury; SLED, sustained low efficiency dialysis; STARRT-AKI, Standard Versus Accelerated Initiation of Dialysis in Acute Kidney Injury trial.