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Early renal replacement therapy reduces risk of death among critically ill patients with acute kidney injury

In a study published online by JAMA, Alexander Zarbock, M.D., of University Hospital Munster, Germany, and colleagues examined whether early (compared with delayed) initiation of renal replacement therapy in patients who are critically ill with acute kidney injury reduces 90-day all-cause mortality. The study is being released to coincide with its presentation at the 53rd European Renal Association – European Dialysis and Transplant Association (ERA-EDTA) Congress.

Acute kidney injury (AKI) is a well-recognized complication of critical illness with a large effect on illness and death. Despite increases in the knowledge of the management of patients who are critically ill, mortality associated with AKI remains high. The optimal timing of initiation of renal replacement therapy (RRT) in critically ill patients with AKI is still unknown. The researchers for this study randomly assigned 231 critically ill patients who had reached stage 2 AKI (per Kidney Disease: Improving Global Outcomes guidelines) and met other criteria, to early (within 8 hours of diagnosis of stage 2; n = 112) or delayed (within 12 hours of stage 3 AKI or no initiation; n = 119) initiation of RRT.

All patients in the early group and 108 of 119 patients (91 percent) in the delayed group received RRT. The researchers found that early initiation of RRT significantly reduced 90-day mortality compared with delayed initiation of RRT (39 percent vs 55 percent of patients died in each group, respectively). More patients in the early group recovered renal function by day 90 (54 percent vs 39 percent). Duration of RRT (9 days vs 25 days) and length of hospital stay (51 days vs 82 days) were significantly shorter in the early group than in the delayed group. There was no significant effect on requirement of RRT after day 90, organ dysfunction, and length of ICU stay.

“Our study provides important feasibility data for an AKI stage-based, biomarker-guided interventional trial in AKI. However, an adequately powered multicenter trial is needed to confirm our results and establish the best time point for the initiation of RRT in critically ill patients with AKI,” the authors write.

Article: Effect of Early vs Delayed Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients With Acute Kidney Injury The ELAIN Randomized Clinical Trial, Alexander Zarbock, MD; John A. Kellum, MD; Christoph Schmidt, MD; Hugo Van Aken, MD; Carola Wempe, PhD; Hermann Pavenstädt, MD; Andreea Boanta, MD; Joachim Gerß, PhD; Melanie Meersch, MD, JAMA, doi:10.1001/jama.2016.5828, published 22 May 2016.