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

Initiation of Dialysis Early Versus Delayed in the Intensive Care Unit Trial

The Initiation of Dialysis Early Versus Delayed in the Intensive Care Unit (IDEAL-ICU) trial was conducted at 29 centers in France to test the hypothesis that an early strategy for initiation of KRT would confer a decrease in 90-day all-cause mortality in critically ill patients with septic shock (within 48 h of initiation of vasopressors) and severe AKI.[31] Patients randomized to the early strategy were to receive KRT within 12 h of being diagnosed with Stage 3 AKI, whereas those included in the delayed arm were to commence KRT if an emergent indication developed or after 48 h of sustained AKI. The trial was prematurely terminated for futility in a planned second interim analysis, after enrollment of only 488 participants (56.4%). The choice of initial KRT modality was also left to the discretion of clinicians, with CRRT selected as the initial modality in 55% of patients. Ninety-seven percentage of patients assigned to the early-strategy group received KRT whereas 62% in the delayed strategy group received KRT. The vast majority of patients in the delayed strategy group who did not receive KRT experienced spontaneous recovery of kidney function. Earlier KRT initiation did not impact 90-day mortality (58 versus 54% in the early and delayed initiation arms, respectively, P = 0.38). KRT dependence among survivors at 90 days did not differ significantly between the groups.