Safe to Delay Dialysis in Critically Ill With Acute Kidney Injury

Maureen Salamon

May 01, 2020

With the exception of urgent indications — and with close patient monitoring — delaying renal replacement therapy (RRT), such as hemodialysis, in critically ill patients with severe acute kidney injury doesn't worsen short-term survival, according to a new meta-analysis published in The Lancet.

And importantly, delayed RRT "was not associated with more adverse events," meaning it can be done safely, said Gertrude Nieuwenhuijs-Moeke, MD, PhD, an anesthesiologist at University Medical Center Groningen in the Netherlands, in an accompanying editorial.

"These findings may change practice," she stressed.

The new research analyzes data from randomized clinical trials published between 2008 and 2019, and is the first to use individual-level patient data, "which is the gold standard," Nieuwenhuijs-Moeke told Medscape Medical News.

"Individual patient data is more accurate than aggregate data, and this research includes all the latest randomized controlled trials performed in this...area," she added, noting that the article is "very strong."

"Based upon these results, which show that early initiation of RRT is not associated with improved outcome, it seems to justify delayed initiation...under close clinical monitoring," she said.

And this delay "might avoid the need for any RRT" in some patients, she noted.

And although not strictly the focus of the research, with AKI emerging as a complication of severe COVID-19, Nieuwenhuijs-Moeke said the new findings are "most likely" translatable to this patient population.

She stressed, however, "The overall clinical condition and accompanying life-threatening complications of AKI should be taken into account [when deciding] whether to start or delay the initiation of RRT."

In Absence of Urgent Indications, RRT Can Be Safely Postponed

Authors Stéphane Gaudry, MD, PhD, of Louis-Mourier Hospital in Colombes, France, and colleagues say that although RRT is frequently used for the management of severe acute kidney injury in critically ill patients, it can be associated with complications.

Hence, the appropriate timing of its initiation has been a subject of intense debate.

To address this issue, Gaudry and colleagues included nine eligible studies comparing delayed with early initiation of RRT — including dialysis, hemofiltration, or continuous venovenous hemofiltration — in 1879 critically ill adult patients.

All had KDIGO (Kidney Disease Improving Global Outcomes) stage 2 or 3 acute kidney injury, or if KDIGO stage was unavailable, a renal Sequential Organ Failure Assessment score of 3 or higher. 

The primary outcome was 28-day all-cause mortality. An estimated 10% to 20% of all hospitalized patients with AKI die, according to recent research.

Researchers contacted the principal investigator of each eligible trial to request individual patient data, and any without AKI or not randomly allocated were excluded.

The 1879 patients were randomly split into the delayed RRT group (946) and early RRT group (933).

Ultimately, 42% (390) of the patients assigned to the delayed RRT group gained spontaneous recovery of renal function and didn't receive RRT.

Data on 28-day mortality were not available for 215 patients.

Among the remaining 1664 patients, deaths didn't differ significantly between the early RRT group, in which 335 of 827 patients (43%) died, and the delayed RRT group, in which 366 of 837 patients (44%) died (risk ratio, 1.01; 95% CI, 0.91 - 1.13).

Similar mortality rates in both groups were also recorded at 60 and 90 days.

"A strategy of early RRT initiation did not confer any tangible clinical benefits for patients in the studies analyzed," the authors write.

Delaying RRT — which could save resources — was also not associated with an increased risk of adverse events, including hyperkalemia, severe bleeding, and severe cardiac rhythm disorder.

"In the absence of urgent indications (eg, life-threatening metabolic complication), initiation of RRT can be safely postponed," they conclude.

And because a delayed RRT initiation strategy entails less frequent use of RRT, "by definition, this approach could have the benefit of saving health resources."

STARRT-AKI Trial Will Shed More Light on Who to Prioritize for RRT

Future research should strive to gather more data among subgroups to determine potential differences in effects of RRT timing, Nieuwenhuijs-Moeke said.

"AKI is a heterogeneous group with different underlying causes and variable physiological processes leading to this syndrome, so there's always a subgroup of patients who could benefit from early RRT," she said.

The 3000-participant STARRT-AKI trial (Standard Versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury), which is awaiting publication, should provide clarity on this in patients with and without sepsis, Nieuwenhuijs-Moeke explained.

"I hope this large RCT will allow for proper subgroup analysis that will allow us to look closer at specific groups of patients," she said.

Nieuwenhuijs-Moeke has disclosed no relevant financial relationships.

Lancet. Published online April 23, 2020. Abstract, Editorial

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