Acute kidney injury (AKI), is also called acute renal failure (ARF), is a disease characterized by the sudden occurrence of kidney failure or kidney damage, which leads to accumulation of waster products from the blood and disturbs the balance of body fluid. AKI affect other organs of the body and is common in patients who are in the hospital, in intensive care units, and especially in older adults.¹. Early initiation of KRT may maintain THE physiologic balance theoretically and reduce volume overload side effects and metabolic derangements. The optimal timing of Kidney Replacement Therapy (KRT) initiation remains unclear.

A recent randomized controlled trial concluded that a careful watching and waiting strategy (during severe AKI in patients without severe hyperkalemia or pulmonary edema, allowed many patients to escape RRT. Also, survival was not affected as compared to the group undergoing immediate RRT. Additionally, data suggested that a delayed strategy could reduce the rate of complications (such as catheter infection) and favour renal function recovery.²

In another randomly study 3,019 critically ill adults with stage 2 or 3 AKI were included. These patients were randomly divided into two groups: accelerated group and standard group. In the accelerated group, therapy was initiated as soon as possible and within 12 hours after patients had met full eligibility criteria and in the standard strategy group renal replacement therapy was discouraged unless conventional indications developed or acute kidney injury persisted for >72 hours). 

There was no difference in the primary outcome including mortality with respect to initiation strategy in 90 days. As far the secondary outcomes, the survivors of the accelerated group were more dependent on kidney replacement therapy (KRT) at 90 days than in the standard group. Patients in the accelerated group experienced shorter intensive care unit stay of 1.6 days as compared to the standard group, but there was no significant difference in ventilator-free days or overall hospital length of stay. The study also revealed that the accelerated group suffered from more adverse events as compared to the standard approach (23.0% vs 16.5%; P < 0.001). Adverse effects included hypotension and severe hypophosphatemia. Incidences of Serious adverse events were rare and similar between the groups. The standard group reported greater fluid accumulation compared to the accelerated group (5,893 vs 2,714 mL) at the time of KRT initiation, but still, no benefit was observed.

The study concluded that no mortality benefits from early initiation and potential signals for harm. Also, the study concluded that pre-emptive KRT initiation at stage 2 AKI without any clinical indications should be discouraged. Also, it was concluded that 40% of patients in the delayed group did not require KRT.³

References:

1. https://www.kidney.org/atoz/content/AcuteKidneyInjury
2. Stéphane Gaudry , J.-P. Q., Alexandre Hertig , Saber Davide Barbar , David Hajage, Jean-Damien Ricard and Didier Dreyfuss Timing of Renal Replacement Therapy for Severe Acute Kidney Injury in Critically Ill Patients. American Journal of Respiratory and Critical Care Medicine 2018, Volume 199, Issue 9, 1-10
3. Sohaney, R.; Yessayan, L. T.; Heung, M. Towards Consensus in Timing of Kidney Replacement Therapy for Acute Kidney Injury? American Journal od Kidney Diseases 2021, IN THE LITERATURE, Vol 77,( 4), , 542-545.