For patients with septic shock and acute kidney injury, is there a benefit to early initiation of renal replacement therapy?

In critically ill patients with septic shock and severe acute kidney injury (AKI), delaying renal replacement therapy (RRT) for at least 48 hours, in the absence of criteria for emergency RRT, does not increase the risk of death and allows some patients to have spontaneous renal recovery. (LOE = 1b)

Barbar SD, Clere-Jehl R, Bourredjem A, et al for the IDEAL-ICU Trial Investigators and the CRICS TRIGGERSEP Network. Timing of renal-replacement therapy in patients with acute kidney injury and sepsis. N Engl J Med 2018;379(15):1431-1442.  [PMID:30304656]

Randomized controlled trial (nonblinded)

Government

Concealed

Inpatient (ICU only)

These investigators randomized patients with early septic shock on vasopressor support and evidence of severe AKI to receive either early or delayed initiation of RRT. The patients' AKI met at least one criteria for the failure stage of the risk, injury, failure, loss, and end-stage kidney disease (RIFLE) classification system (oliguria, anuria, or serum creatinine level 3 times the baseline level). In the early group, RRT was initiated within 12 hours of diagnosis of AKI; in the delayed group, RRT was initiated after 48 hours. If patients in the delayed group developed an emergency indication for RRT, such as severe hyperkalemia, metabolic acidosis, or fluid overload prior to the 48 hours mark, they were immediately started on RRT. If, however, spontaneous renal recovery occurred before 48 hours, then RRT was not initiated. The 2 groups were similar at baseline, with a mean age of 69 years and similar comorbidities. The trial was stopped early because of futility. There was no significant difference detected in 90-day mortality with early initiation of RRT (58% in early group vs 54% in delayed group; P = .38). Although there was less use of RRT in the delayed group, there were no differences in the number of days free from mechanical ventilator and vasopressor use or in intensive care unit or hospital length of stay. Almost 30% of patients in the delayed group did not require RRT because of spontaneous renal recovery while 17% underwent emergency RRT prior to the 48-hour mark.