Good morning
This week we discuss the results of the IDEAL - ICU ( The Initiation of Dialysis Early Versus Delayed in the Intensive Care Unit ) study which appears to challenge the benefits of early RRT in the ICU.
Barbar et al Timing of Renal-Replacement Therapy in Patients with Acute Kidney Injury and Sepsis.
N Engl J Med 2018; 379: 1431-42
Acute Kidney Injury is very frequent amongst critically ill septic patients. Attributable mortality is also high. The popular belief is that early aggressive RRT is beneficial in terms of ICU survival and long term recovery of renal function.
The IDEAL ICU multicenter study attempted to evaluate whether initiating RRT as soon as a diagnosis of "Failure" as per RIFLE criteria is made, confers survival advantage to the critically ill patient.
They identified patients who satisfied the criteria to define Failure as per the RIFLE criteria. They then randomized this cohort into those who received RRT as soon as failure was diagnosed and into those in whom RRT was initiated only when metabolic problems or hyperkalemia or fluid overload mandated such therapy.
Originally this study was designed to recruit 800+ patients to show a 10% difference in outcomes with 80% power. The primary end point was 90 day mortality. Secondary outcomes were death at 28 days and at 180 days, RRT free days, ventilator and vasopressor free days at 28 days, ICU and hospital LOS, adverse events during the entire ICU stay, fluid balance in the first 7 days after enrollment; the need for emergency renal-replacement therapy in the delayed strategy group; death of patients in the delayed strategy group in whom at least one criterion for emergency renal-replacement therapy was met; and dependence on renal-replacement therapy at hospital discharge.
The study was stopped midway due to apparent futility of the early RRT strategy. Fluid balance also did not show any beneficial pattern with early RRT. The incidence of metabolic complications was higher in the delayed RRT group. Emergency RRT was needed in 17% of patients in the delayed group ( 41 patients). Twenty eight of the 41 died. The dependence on the RRT at hospital discharge was also not significantly different between the two groups.
The authors concluded that " Among patients with septic shock who had severe acute kidney injury, there was no significant difference in overall mortality at 90 days between patients who were assigned to an early strategy for the initiation of renal-replacement therapy and those who were assigned to a delayed strategy."
My view:
1. We need to think twice before initiating RRT just on the basis of creatinine.
2. Failure may not be the ideal comparator. Injury stage may need to be focused on
3. In the delayed strategy emergency need for RRT could be associated with higher mortality
Sir..i have few comments
ReplyDelete1. Can we actually justify the binary division of RRT into early and late because our initiation of early RRT can be actually late for some patients and late RRT can be avoided if we give somemore time for recovery from AKI
2. All the 3 studies which have been published in last 2 years, had a binary divison of groups into early and late..I think , they should have been further divison or sub group analysis..
For example like 4 groups (like early early, early late, late early and late late)..may be this may answer our question of when exactly to start without increasing risk of emergency RRT and mortality.
Rajesh, your point is very pertinent. Patients who tolerate high creatinine and remain non oliguric may not need RRT. Those who sustain injury and do not have the bandwidth to handle it are the ones who should be evaluated.
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