BACKGROUND Acute kidney injury is common in critically ill patients, many of whom receive renal-replacement therapy. However, the most effective timing for the initiation of such therapy remains uncertain. METHODS We conducted a multinational, randomized, controlled trial involving critically ill patients with severe acute kidney injury. Patients were randomly assigned to receive an accelerated strategy of renal-replacement therapy (in which therapy was initiated within 12 hours after the patient had met eligibility criteria) or a standard strategy (in which renal-replacement therapy was discouraged unless conventional indications developed or acute kidney injury persisted for >72 hours). The primary outcome was death from any cause at 90 days. RESULTS Of the 3019 patients who had undergone randomization, 2927 (97.0%) were included in the modified intention-to-treat analysis (1465 in the accelerated-strategy group and 1462 in the standard-strategy group). Of these patients, renal-replacement therapy was performed in 1418 (96.8%) in the accelerated-strategy group and in 903 (61.8%) in the standard-strategy group. At 90 days, death had occurred in 643 patients (43.9%) in the accelerated-strategy group and in 639 (43.7%) in the standard-strategy group (relative risk, 1.00; 95% confidence interval [CI], 0.93 to 1.09; P=0.92). Among survivors at 90 days, continued dependence on renal-replacement therapy was confirmed in 85 of 814 patients (10.4%) in the accelerated-strategy group and in 49 of 815 patients (6.0%) in the standard-strategy group (relative risk, 1.74; 95% CI, 1.24 to 2.43). Adverse events occurred in 346 of 1503 patients (23.0%) in the accelerated-strategy group and in 245 of 1489 patients (16.5%) in the standard-strategy group (P<0.001). CONCLUSIONS 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.
Bibliographical noteFunding Information:
Supported by grants from the Canadian Institutes of Health Research (MOP142296 and 389635), the Canadian Institutes of Health Research in partnership with Baxter (IPR-139081), the National Health Medical Research Council of Australia (1127121), the Health Research Council of New Zealand (17/204), and the Health Technology Assessment Program of the United Kingdom National Institutes of Health Research (17/42/74). In 2017, the trial was adopted by the United Kingdom National Institutes for Health Research as a portfolio study. The Canadian Critical Care Trials Group is supported by a grant from the Canadian Institutes of Health Research (138094). Dr. Bagshaw is supported by a Canada Research Chair in Critical Care Nephrology. Dr. Nichol is supported by a Health Research Board of Ireland Clinical Trial Network award. Dr. Schneider is supported by a grant from the Leenaards Foundation. Dr. Young is supported by a Clinical Practitioner Research Fellowship from the Health Research Council of New Zealand.
Copyright © 2020 Massachusetts Medical Society.
- Acute Kidney Injury/mortality
- Critical Illness/therapy
- Intention to Treat Analysis
- Middle Aged
- Renal Replacement Therapy/adverse effects
- Treatment Outcome