While some recommend to initiate renal replacement therapy (RRT) as soon as severe acute kidney injury, on the other hand some advocate a delayed strategy wherein they suggest waiting until the patient develops an indication for dialysis. In the standard versus accelerated initiation of renal replacement therapy in acute kidney injury (STARRT-AKI) trial, over 3000 critically ill patients with severe AKI and no emergency indication for RRT were randomly assigned to an early or delayed strategy. The trial results showed that here was no difference in mortality at 90 days; however, patients in the early strategy group had increased chances of remaining RRT-dependent, need rehospitalization, and have an adverse event. The authors recommended against early initiation of RRT, since it may lead to an increased health care utilization without improving outcomes. In fact, sometimes there may be a worsening of outcomes.

In the study, of the 3019 patients who underwent randomization, 2927 (97.0%) were included in the modified intention-to-treat analysis. Of these patients, renal-replacement therapy was performed in 1418 (96.8%) in the accelerated strategy group and in 903 (61.8%) in the standard-strategy group. At 90 days, death had occurred in 643 patients (43.9%) in the accelerated-strategy group and in 639 (43.7%) in the standard-strategy group (relative risk, 1.00; 95% confidence interval [CI], 0.93 to 1.09; P=0.92). Among the survivors at 90 days, on continued dependence on renal-replacement therapy was confirmed in 85 of 814 patients (10.4%) in the accelerated-strategy group and in 49 of 815 (6.0%) in the standard-strategy group (relative risk, 1.74; 95% CI, 1.24 to 2.43).

Renal replacement therapy is indicated in patients with severe kidney injury, and multiple modalities are available. These include intermittent haemodialysis, continuous renal replacement therapies, and hybrid therapies or prolonged intermittent renal replacement therapies (like sustained low-efficiency dialysis and extended-duration dialysis). Based on the results of the STARRT-AKI trial, it was concluded, that among critically ill patients with acute kidney injury, an accelerated renal replacement strategy was not linked with a reduced risk of death at 90 days compared with a standard strategy.

References

1. STARRT-AKI investigators, et al. Timing of initiation of renal-replacement therapy in acute kidney injury. N Engl J Med. 2020; 383 (3): 240-251.