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

Artificial Kidney Initiation in Kidney Injury Trial

The Artificial Kidney Initiation in Kidney Injury (AKIKI) trial was a multicenter, open-label RCT conducted at 31 centers in France.[30] The trial included 620 patients with KDIGO stage 3 AKI who required intravenous vasopressors and/or mechanical ventilation and did not have a life-threatening complication secondary to AKI. The trial included patients from mixed medical--surgical ICUs, with nearly 56% having septic shock. Participants were randomized to an early (within 6 h of KDIGO stage 3 AKI documentation, n = 311) or delayed (KRT initiated in the presence of oliguria or anuria persisting for more than 72 h, BUN more than 112 mg/dl, hyperkalemia, metabolic acidosis, and/or pulmonary edema because of fluid overload, n = 308) initiation strategy. KRT modality was left to the discretion of clinicians, with intermittent modalities predominating. All but six patients randomized to the early strategy received KRT whereas 51% of those in the delayed arm commenced KRT. Among participants who received KRT, those included in the delayed strategy arm initiated KRT 55 h later than those in the early arm. Mortality at 60 days was not different between the two arms: 48.5% in the early-strategy versus 49.7% in the delayed-strategy [hazard ratio 1.03 95% confidence interval (CI) 0.82–1.29, P = 0.79]. Patients randomized to early KRT initiation had fewer dialysis-free days (17 versus 19 days, P < 0.001) and a higher risk of iatrogenic complications, notably central venous catheter-associated infections and hypophosphatemia.