Timing of Kidney Replacement Therapy Initiation in Acute Kidney Injury

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

Disclosures

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

In This Article

Early Versus Late Initiation of Renal Replacement Therapy in Critically Ill Patients With Acute Kidney Injury Trial

The Early Versus Late Initiation of Renal Replacement Therapy In Critically Ill Patients With Acute Kidney Injury (ELAIN) trial was a single-center RCT conducted in Germany. It included 231 critically ill patients virtually all of whom had recently undergone surgery.[28] The trial enrolled adult patients with KDIGO stage 2 AKI (more than two-fold increase of serum creatinine from baseline or urine output < 0.5 ml/kg/h for ≥12), a plasma neutrophil gelatinase-associated lipocalin (NGAL) greater than 150 ng/ml, and one or more of the following conditions: severe sepsis or septic shock (sepsis needing vasopressor support), fluid overload refractory to diuretics or developing or worsening Sequential Organ Failure Assessment (SOFA) score at least 2. Participants were randomized to two groups: early KRT initiation (KRT to be started within 8 h of KDIGO stage 2 AKI criteria being met, n = 112) or delayed initiation (KRT to be started if patient progressed to KDIGO stage 3 AKI (greater than three-fold increase of serum creatinine from baseline or urine output less than 0.3 ml/kg/h for ≥4 h or anuria for 12 h) or developed an AKI-related emergency (n = 119). Initially all patients received continuous venovenous hemodiafiltration (CVVDHF), with the option of transitioning to intermittent modalities after 7 days of therapy. All patients in the early initiation arm received KRT as did 91% in the delayed initiation arm. The median intergroup difference in the time from randomization to KRT initiation was 21 h (interquartile range 18–24). Early initiation of KRT reduced the primary endpoint of 90-day mortality compared with delayed initiation (39 versus 55%; P = 0.03). Patients allocated to earlier initiation also experienced a shorter duration of mechanical ventilation and a shorter hospital stay. The rate of adverse events was similar in both arms. A 1-year follow-up of ELAIN participants demonstrated that major adverse kidney events, defined as the composite of persistent kidney dysfunction (25% decline in eGFR compared with baseline), dialysis dependence, and mortality were persistently lower among patients allocated to early KRT.[29]

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