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Many critically ill patients develop acute kidney injury (AKI); some require renal replacement therapy (RRT). Early initiation might stave off complications of AKI, such as volume overload and metabolic acidosis; however, early RRT also might expose patients who would have recovered without intervention to additional risks.
Investigators randomized nearly 3000 patients with severe AKI (Kidney Disease: Improving Global Outcomes [KDIGO] stage 2 or 3), but without emergency indications for RRT, to either early (within 12 hours of randomization) or standard initiation of RRT. More than half of patients had sepsis, and three quarters were receiving mechanical ventilation. Chronic kidney disease was common (44%). Nearly all patients in the early-initiation arm received RRT, whereas only 62% in the standard-initiation group received RRT. Mortality at 90 days and length of hospitalization were the same between groups. Dependence on RRT at 90 days was more common among the patients with early RRT (10% vs. 6%).
The STARRT-AKI Investigators.Timing of initiation of renal-replacement therapy in acute kidney injury. N Engl J Med 2020 Jul 16; 383:240. (https://doi.org/10.1056/NEJMoa2000741)
Comment
This multinational pragmatic trial is the largest to examine timing of RRT in critically ill patients. Similar to what was shown in smaller studies, in many patients, AKI will resolve without RRT. These results support the practice of waiting to start RRT until it is absolutely indicated: development of hyperkalemia, severe acidosis, or volume overload affecting oxygenation.