Early initiation of RRT in critically ill patients with AKI does not lower 90-day mortality

Référence

The STAART-AKI Investigators. Timing of initiation of renal-replacement therapy in acute kidney injury. N Engl J Med;383:240-51.

Sommaire

In this multinational study, investigators randomized critically ill adult patients with severe AKI to receive accelerated initiation of RRT (n=1465) or standard initiation (n=1462). Patients with emergency indications for RRT and those with advanced chronic kidney disease were excluded, amongst others. After randomization, full eligibility was confirmed by excluding patients who were determined by their primary physicians to require emergency RRT or be likely to have imminent recovery of renal function. In the accelerated strategy group, patients started RRT within 12 hours of confirmation of full eligibility. In the standard group, RRT was only started if patients had evidence of hyperkalemia, severe metabolic acidosis, severe respiratory failure, or persistent acute kidney injury for at least 72 hours. The two groups were balanced at baseline: 44% had chronic kidney disease and 58% had sepsis. In the accelerated group, RRT was initiated at a median of 6.1 hours in 96.8% of patients, whereas in the standard group, RRT was initiated at a median of 31.1 hours in 61.8% of patients. No significant difference in deaths were detected at 90 days (about 44% in both groups). Accelerated strategy patients were more likely to be dependent on RRT at 90 days (10.4% vs. 6.0%, RR 1.74, 95% CI 1.24-2.43) and had a higher risk of re-hospitalization (20.9% vs. 17.0%, RR 1.23, 95% CI 1.02-1.49). Adverse events, most commonly hypotension and hypophosphatemia, were also more likely in the accelerated strategy group (23.0% vs. 16.5%, RR 1.40, 95% CI 1.21-1.62). Quality of life scores were similar in the two groups.