Kidney Res Clin Pract > Volume 40(4); 2021 > Article |
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AKI, acute kidney injury; CRRT, continuous renal replacement therapy.
Reproduced from the article of Ostermann et al. (Contrib Nephrol 2016;187:106-120) [22] with the permission from S. Karger AG.
Reproduced from the article of Ostermann et al. (Contrib Nephrol 2016;187:106-120) [22] with the permission from S. Karger AG.
Guideline | Recommendation |
---|---|
Kidney Disease: Improving Global Outcomes (KDIGO) [42] | Initiate RRT emergently with life-threatening changes in fluid, electrolyte, and acid-base balance. (Not graded) |
Consider the broader clinical context, the presence of conditions that can be modified by RRT, and trends of laboratory tests (rather than BUN and creatinine thresholds alone) when making the decision to start RRT. (Not graded) | |
National Institute for Health and Care Excellence (NICE) [45] | Discuss any potential indications for RRT with a nephrologist, pediatric nephrologist, and/or critical care specialist to ensure that the therapy is started as soon as needed |
Refer adults, children, and young people immediately for RRT if any of the following are not responding to medical management: | |
• Hyperkalemia | |
• Metabolic acidosis | |
• Symptoms or complications of uremia | |
• Fluid overload | |
• Pulmonary edema | |
Base the decision to start RRT on the condition of the adult, child, or young person as a whole and not on isolated urea, creatinine, or potassium value | |
French Intensive Care Society (SRLF) [43] | RRT should be initiated without delay in life-threatening situations, including hyperkalemia, metabolic acidosis, and refractory pulmonary edema (Expert opinion; strong agreement) |
The available data are insufficient to define optimal timing of initiation of RRT outside of life-threatening situations (Expert opinion; strong agreement) | |
The Japanese Clinical Practice Guideline [44] | There is little evidence to support the theory that early initiation of blood purification improves the outcomes of AKI. Initiation of RRT should be based upon broad considerations of the clinical symptoms and disease conditions (Not graded; C) |
Trial | ELAIN [46] | AKIKI [47] | IDEAL-ICU [48] | STARRT-AKI [49] |
---|---|---|---|---|
Country | Germany | France | France | Multinational (15) |
Centers | Single center | Multicenter (31) | Multicenter (29) | Multicenter (168) |
Patients randomized | 231 | 620 | 488 | 3019 |
Patient population | Mixed medical & surgical ICU (94.8% surgical) | Mixed medical & surgical ICU (79.7% medical) | Mixed medical & surgical ICU | Mixed medical & surgical ICU |
Inclusion criteria | KDIGO stage 2 AKI and plasma NGAL > 150 ng/mL and at least one of the following: severe sepsis; use of vasopressors; refractory fluid overload; and/or nonrenal organ dysfunction | KDIGO stage 3 AKI and receiving mechanical ventilation and/or vasoactive support | Adults with severe AKI and septic shock | Critically ill patients and kidney dysfunction and those with severe AKI (KDIGO stage 2 or 3) |
Intervention | ||||
Early RRT | KDIGO stage 2 (within 8 hr) | KDIGO stage 3 (within 6 hr) | Failure stage of RIFLE (within 12 hr) | Fulfills eligibility criteriad (within 12 hr) |
Delayed RRT | KDIGO stage 3 (within 12 hr) or conventional indications for RRTa | Conventional indications for RRTb | Conventional indications for RRTc | Until the occurrence of one or more of the applicable criteriae |
Median time from randomization to RRT (hr) | 6/25.5 | 2/57.0 | 7.6/51.5 | 6.1/31.1 |
Percentage receiving RRT | 100.0/90.8 | 98.0/51.0 | 97.0/62.0 | 96.8/61.8 |
RRT modality | CRRT 100% | iHD, CRRT | iHD, CRRT | iHD, CRRT |
Primary outcome | 90-day mortality | 60-day mortality | 90-day mortality | 90-day mortality |
Early RRT (%) | 39.3 | 48.5 | 58 | 43.9 |
Delayed RRT (%) | 54.7 | 49.7 | 54 | 43.6 |
RRT dependence among survivors at day 90 (%) | 13.4/15.1 | 2/5 (at day 60) | 2/3 | 10.4/6.0 |
Hospital stay (day) | 51/82f (p < 0.001) | 29/32g | 22/21g | 28/29g |
Adverse event (%) | Not significant | Hypophosphatemia (22/15) (p = 0.03) | Hyperkalemia (0/4) (p = 0.03) | 23/17 (p < 0.001) |
AKI, acute kidney injury; AKIKI, Artificial Kidney Initiation in Kidney Injury trial; CRRT, continuous renal replacement therapy; ELAIN, Early Versus Late Initiation of RRT in Critically Ill Patients with Acute Kidney Injury trial; ICU, intensive care unit; IDEAL-ICU, Initiation of Dialysis Early Versus Delayed in the Intensive Care Unit trial; iHD, intermittent hemodialysis; KDIGO, Kidney Disease: Improving Global Outcomes; NGAL, neutrophil gelatinase-associated lipocalin; RRT, renal replacement therapy; STARRT-AKI, Standard versus Accelerated Initiation of Renal-Replacement Therapy in Acute Kidney Injury trial.
aSerum urea > 36 mmol/L; K > 6.0 mmol/L; Mg > 4 mmol/L; urine output < 200 mL/12 hours or anuria; organ edema resistant to diuretics.
bbSevere hyperkalemia (>6.0 mmol/L); severe pulmonary edema refractory to diuretics; severe acidosis (pH < 7.15); urea > 40 mmol/L; oligo-anuria > 72 hours.
cSevere hyperkalemia (>6.5 mmol/L); severe pulmonary edema refractory to diuretics; severe acidosis (pH < 7.15); no renal function recovery after 48 hours.
dAt least two of the following: 2-fold increase in serum creatinine from baseline; urine output < 6 mL/kg in the preceding 12 hours; whole-blood NGAL > 400 ng/mL.
Jung Nam An
https://orcid.org/0000-0001-5108-1005
Sung Gyun Kim
https://orcid.org/0000-0002-5034-0527
Young Rim Song
https://orcid.org/0000-0002-0416-4745
Nephrology consultation improves the clinical outcomes of patients with acute kidney injury