Accelerated dialysis may not improve survival for patients with AKI
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Initiating dialysis within 12 hours of developing AKI, deemed the “accelerated” approach, was not associated with lower mortality risk compared with starting therapy after 72 hours, according to study results.
“This is the largest trial to tackle a question that has been vexing clinicians for more than 30 years,” Sean M. Bagshaw, MD, of the department of critical care medicine at the University of Alberta in Canada, said in a related press release. “The critical care and nephrology communities have been eagerly awaiting further information to guide the question, ‘When is the ideal time to start dialysis therapy in critically ill patients admitted to Intensive Care Unit (ICU) with acute kidney injury?’”
To investigate, Bagshaw and colleagues randomized 1,148 patients to the accelerated strategy group and 903 patients to a standard strategy group. According to the researchers, for patients in the standard strategy group, clinicians were “discouraged” from initiating renal replacement therapy until patients developed a serum potassium level of 6 mmoL or more per liter, a pH of 7.20 or less, or a serum bicarbonate level of 12 mmoL per liter or less; severe respiratory failure; volume overload; or persistent AKI for at least 72 hours.
Mortality was similar between groups at 90 days, occurring in 43.9% of patients in the accelerated-strategy group and in 43.7% in the standard-strategy group (relative risk = 1).
When considering patients who were survivors at 90 days, researchers determined that 10.4% of those in the accelerated-strategy group remained dependent on RRT vs. 6% in the standard-strategy group (RR = 1.74).
Further findings indicated that while patients in the accelerated-strategy group had shorter stays in the ICU, they also had had a higher risk of rehospitalization.
In addition, safety between the two strategies was considered, with adverse events occurring in 23% of patients in the accelerated-strategy group vs. 16.5% in the standard-strategy group.
Co-investigator Ron Wald, MD, MPH, associate professor of medicine at the University of Toronto, commented on the results, suggesting a lack of evidence on appropriate RRT timing has caused clinicians to approach dialysis initiation “very differently.”
"Dialysis is life-saving, but it has potential harms,” he said in the press release. “By initiating it more judiciously, it will expose patients to less risk and potentially reduce health care costs without any negative impact on patient survival."
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