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When Should Renal Replacement Therapy Start After Acute Kidney Injury?


Just when renal replacement therapy should start after acute kidney injury has been debated.

Acute kidney injury happens often in critically ill patients, and has been a common feature of coronavirus disease 2019 (COVID-19). Many of these patients require renal replacement therapy, such as dialysis.

However, just when renal replacement therapy should start has been debated. Results from a team across several institutions who sought to answer this question, including the STARRT-AKI investigators, and scientists from Canada, Australia, New Zealand, and Ireland, appeared recently in the New England Journal of Medicine.

Investigators randomized 3019 patients, and 2927 were included in the intent-to-treat analysis; 1465 were treated in an accelerated strategy that started renal replacement therapy within 12 hours after the patient met criteria, while 1462 received the standard strategy, in which therapy was not started for at least 3 days (at least 72 hours). The primary outcome was death from any cause at 90 days.

In the accelerated group, 1418 (96.8%) received therapy, while 903 (61.8%) received treatment in the standard group. At 90 days, death occurred in 643 patients in the accelerated group (43.9%), and in 639 (43.7%) in the standard group, for a relative risk of 1.00 (95% CI, 0.93-1.09, P = .92).

Of those who lived at least 90 days, ongoing dependence on renal replacement therapy was seen in 85 of the 814 patients (10.4%) in the accelerated strategy group, and in 49 of the 815 patients (6.0%) of the standard group, for a relative risk of 1.74 (95% CI, 1.24-2.43).

In the accelerated group, 346 of the 1503 (23.0%) had adverse events, while 245 of 1489 (16.5%) in the standard group (P < .001) did so.

“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,” the authors concluded.


The STARRT-AKI Investigators, et al. Timing of initiation of renal-replacement therapy in acute kidney injury [published online July 16, 2020]. N Engl J Med. DOI: 10.1056/NEJMoa2000741

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