Barbar SD, et al. - In this multicenter, randomized, controlled trial, researchers explored the ideal time for renal-replacement therapy (RRT) initiation for patients with acute kidney injury and sepsis. A total of 488 patients underwent randomization to receive RRT either within 12 hours after documentation of failure-stage acute kidney injury (early strategy) or after a delay of 48 hours if renal recovery had not occurred (delayed strategy). Findings revealed that patients who were assigned to an early strategy for RRT initiation and those who were assigned to a delayed strategy were not significantly different in overall mortality at 90 days.

Methods

• Researchers randomized 488 patients with early-stage septic shock who also had severe acute kidney injury at the failure stage of the risk, injury, failure, loss, and end-stage kidney disease (RIFLE) classification system—but without life-threatening complications related to acute kidney injury—to RRT within 12 hours following failure-stage acute kidney injury (early strategy) documentation or after a delay of 48 hours if renal recovery had not occurred (delayed strategy).
• A serum creatinine level three times the baseline level (or ≥ 4 mg/dL with a rapid increase of ≥ 0.5 mg/dL), urine output < 0.3 mL/kg of body weight per hour for ≥ 24 hours, or anuria for ≥ 12 hours characterized the failure stage of the RIFLE classification system.
• Death at 90 days was the primary outcome assessed.

Results

• Owing to the futility after the second planned interim analysis, the trial was stopped early.
• Cohorts were not significantly different regarding the characteristics at baseline.
• Follow-up data at 90 days were available for 477 patients; death was reported for 58% of the patients in the early-strategy group (138/239 patients) and 54% in the delayed-strategy group (128/238 patients; P=0.38).
• RRT was not administered to 38% (93) of patients in the delayed-strategy group.
• In the delayed-strategy group, 17% (41) of the patients met criteria for emergency RRT.