Nephrology in critical care · When to start dialysis
Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury
| Design | Multicentre randomised controlled trial |
|---|---|
| Treatment | Accelerated initiation of renal replacement therapy |
| Control | Standard, deferred initiation |
| Population | 2927 analysed critically ill patients with acute kidney injury: 1465 accelerated and 1462 standard |
| Follow-up | 90 days |
| Primary endpoint | Death from any cause at 90 days |
| Result | Among the 2927 patients in the modified intention-to-treat analysis, accelerated initiation did not reduce 90-day mortality and was associated with greater dependence on renal replacement therapy at 90 days. Adverse events occurred in 346 of 1503 (23.0%) with accelerated initiation versus 245 of 1489 (16.5%) with the standard strategy (p<0.001). |
| Secondary endpoints | Dependence on renal replacement therapy at 90 days, adverse events |
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. (Funded by the Canadian Institutes of Health Research and others; STARRT-AKI ClinicalTrials.gov number, NCT02568722.).
The trial authors, in the published abstract
The largest trial of dialysis timing, and it makes waiting the default. Many patients randomised to the standard arm never needed dialysis at all, which is the practical argument — as with tracheostomy timing in TracMan.
Bagshaw SM, Wald R, Adhikari NKJ, et al. Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury. N Engl J Med 2020 Jul 16;383(3):240-251.