Timing of Kidney Replacement Therapy Initiation in Acute Kidney Injury

Alejandro Y. Meraz-Muñoz; Sean M. Bagshaw; Ron Wald


Curr Opin Nephrol Hypertens. 2021;30(3):332-338. 

In This Article

Can we Predict the Receipt of Kidney Replacement Therapy in Acute Kidney Injury?

The decision to start KRT preemptively would be optimally informed by knowledge that a given patient's clinical course is likely to culminate with a need for KRT. However, in these patients, the receipt of KRT has two diametrically opposed competing 'risks': mortality before KRT is started and kidney recovery. An ideal biomarker would identify patients who will survive long enough without kidney recovery, and therefore, be in a position to receive KRT. A recent meta-analysis evaluating the performance of novel biomarkers for predicting KRT in AKI, concluded that the current strength of evidence prevents their routine use for clinical decision-making on when to start KRT.[16] More recently, urinary C-C motif chemokine ligand 14 (CCL14) was found to accurately predict persistent stage 3 AKI for 72 h or longer; however, its role in guiding the initiation of KRT is still not defined.[17]

The furosemide stress-test (FST), which provides a marker of tubular integrity by evaluating urine output following the administration of a standard bolus of furosemide, has been shown to accurately predict AKI progression from stages 1–2 to stage 3, which includes the receipt of KRT. This test has shown favourable performance compared with other putative AKI biomarkers in predicting unfavorable outcomes.[18–20] A recent pilot trial conditioned randomization to early or later KRT based on unresponsiveness to the FST. Among the 44 FST responders (urine output >200 ml in 2 h), only 13.6% of patients ultimately received KRT.[21]