More-delayed strategy, waiting further before initiating renal replacement therapy
Control
Delayed strategy
Population
278 patients with severe acute kidney injury: 137 delayed and 141 more-delayed
Inclusion criteria
Oliguria for more than 72 hours or blood urea nitrogen above 112 mg/dL, without a severe complication mandating immediate renal replacement therapy.
Follow-up
60 days
Primary endpoint
Number of days alive and free of renal replacement therapy
Result
Median RRT-free days were 12 (IQR 0 to 25) with the delayed strategy and 10 (IQR 0 to 24) with the more-delayed strategy (p=0.93). Complications potentially related to acute kidney injury or to renal replacement therapy did not differ between groups. On multivariable analysis the hazard ratio for death at 60 days was 1.65 (95% CI 1.09 to 2.50, p=0.018) with the more-delayed strategy.
Secondary endpoints
60-day mortality, complications of acute kidney injury
In severe acute kidney injury patients with oliguria for more than 72 h or blood urea nitrogen concentration higher than 112 mg/dL and no severe complication that would mandate immediate RRT, longer postponing of RRT initiation did not confer additional benefit and was associated with potential harm.
The trial authors, in the published abstract
How it has aged
Marks the far edge of the watchful-waiting approach that STARRT-AKI supports. There is a point beyond which delay stops being conservative and starts being dangerous, and this trial locates it: no gain in dialysis-free days, and a 65% higher adjusted hazard of death at 60 days.
Publications
Comparison of two delayed strategies for renal replacement therapy initiation for severe acute kidney injury (AKIKI 2): a multicentre, open-label, randomised, controlled trial
Gaudry S, Hajage D, Martin-Lefevre L, et al. Comparison of two delayed strategies for renal replacement therapy initiation for severe acute kidney injury (AKIKI 2): a multicentre, open-label, randomised, controlled trial. Lancet 2021 Apr 3;397(10281):1293-1300.
No benefit from further postponement
More complications potentially related to acute kidney injury