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Accelerated Renal-Replacement Therapy Not Beneficial for Severe Kidney Injuries

More than 40% of critically ill patients died within 90 days regardless of timing of renal-replacement therapy.

Sean M. Bagshaw, MD

Acute kidney injuries (AKI) are common for critically ill patients and often lead to renal-replacement therapy. However, the most effective timing for the initiation of this therapy is unknown.

An international research team hailing from 5 different countries, led by Sean M. Bagshaw, MD, the Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, conducted a multinational, randomized, controlled trial examining critically ill patients with severe acute kidney injuries and what the optimal timing for renal-replacement therapy was.

Each patient was randomly assigned to receive an accelerated strategy of renal-replacement therapy where therapy was initiated within 12 hours following the patient meeting eligibility criteria or a standard strategy where renal-replacement therapy was discouraged unless conventional indications developed or acute kidney injury persisted for more than 72 hours.

The investigators sought a primary outcome of death from any cause at 90 days.

A total of 3019 patients were randomized, 2927 (97.0%) of which were included in the modified intention-to-treat analysis (1465 in the accelerated-strategy group and 1462 in the standard-strategy group).

Renal-replacement therapy was performed in 1418 (96.8%) of individuals in the accelerated-strategy group and 903 (61.8%) of patients in the standard-strategy group. At the conclusion of the 90 day period, 643 patients (43.9%) in the accelerated-strategy group and 639 (43.7%) participants in the standard-strategy group had died (RR, 1.00; 95% CI, 0.93-1.09; P = 0.92).

For the survivors, 85 (10.4%) patients continued dependence at 90 days on renal-replacement therapy and 49 (6.0%) in the standard-strategy group (RR, 1.74; 95% CI, 1.24-2.43).

The investigators also identified adverse events occurring in 346 (23.0%) of individuals in the accelerated-strategy group and 245 (16.5%) in the standard-strategy group (P <0.001).

“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,” the authors wrote.

Earlier this year, researchers found proteinuria levels following an acute kidney injury could help predict the future risk of the loss of renal function.

A team from several different institutions, led by Chi-yuan Hsu, MD, Division of Nephrology, University of California School of Medicine, San Francisco, found that more widespread quantification of proteinuria after a hospitalized acute kidney injury should be considered to better evaluate the risk of future kidney disease progression.

In a matched cohort study involving 1538 patients, half of which have an acute kidney injury during hospitalization, the investigators found higher urine albumin-to-creatinine ratio (ACR) quantified 3 months following hospitalization discharge with an AKI was linked to an increased risk of kidney disease progression and served as a risk discriminator.

Higher post-AKI urine ACR level was associated with increased risk of kidney disease progression (HR, 1.53 for each doubling; 95% CI, 1.45-1.62), and urine ACR measurement was a strong discriminator for future kidney disease progression (C statistic, .82).

The study, “Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury,” was published in the New England Journal of Medicine.