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Title: Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury.
Austin Authors: Bagshaw, Sean M;Wald, Ron;Adhikari, Neill K J;Bellomo, Rinaldo ;da Costa, Bruno R;Dreyfuss, Didier;Du, Bin;Gallagher, Martin P;Gaudry, Stéphane;Hoste, Eric A;Lamontagne, François;Joannidis, Michael;Landoni, Giovanni;Liu, Kathleen D;McAuley, Daniel F;McGuinness, Shay P;Neyra, Javier A;Nichol, Alistair D;Ostermann, Marlies;Palevsky, Paul M;Pettilä, Ville;Quenot, Jean-Pierre;Qiu, Haibo;Rochwerg, Bram;Schneider, Antoine G;Smith, Orla M;Thomé, Fernando;Thorpe, Kevin E;Vaara, Suvi;Weir, Matthew;Wang, Amanda Y;Young, Paul;Zarbock, Alexander
Affiliation: Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton
Division of Nephrology, St. Michael's Hospital and the University of Toronto, Li Ka Shing Knowledge Institute, Department of Medicine, and Applied Health Research Centre, St. Michael's Hospital, the Dalla Lana School of Public Health, the Institute of Health Policy, Management, and Evaluation, University of Toronto, and the Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and the University of Toronto, Toronto, Canada
Department of Medicine, Université de Sherbrooke and Centre de Recherche du Centre Hospitalier Universitaire (CHU) de Sherbrooke, Sherbrooke, Canada
Division of Critical Care, Juravinski Hospital, McMaster University, Hamilton, ON, Canada
Division of Nephrology, London Health Sciences Centre, London, ON, Canada
Intensive Care
Royal Melbourne Hospital, School of Medicine, University of Melbourne, Melbourne, VIC, Australia
Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
George Institute for Global Health, Concord Clinical School, Faculty of Medicine, University of Sydney, Sydney, Australia
Institute of Primary Health Care, University of Bern, Bern, Switzerland
Department of Critical Care Medicine, CHU Vaudois, Lausanne, Switzerland
Hôpital Louis Mourier and Université Léonard de Vinci, INSERM Unité UMR S1155, Sorbonne Université and Université de Paris, Paris, Hôpital Avicenne, Bobigny, and Hôpital Universitaire François Mitterrand, Lipness Team, INSERM Research Center Lipids, Nutrition, Cancer-Unité Mixte de Recherche 1231 and Laboratoire d'Excellence LipSTIC, Centre d'Investigation Clinique-Epidemiologie Clinique, CHU Dijon-Bourgogne, and INSERM Centre d'Investigation Clinique 1432, Université de Bourgogne, Dijon, France
Department of Critical Care Medicine, Peking Union Medical College Hospital, Beijing, China
Department of Critical Care Medicine, Zhongda Hospital Southeast University, Nanjing, China
Department of Intensive Care, University of Ghent, Ghent, Belgium
Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria
Vita Salute San Raffaele University and IRCCS San Raffaele Scientific Institute, Milan
Divisions of Nephrology and Critical Care Medicine, University of California, San Francisco, San Francisco
Wellcome-Wolfson Institute for Experimental Medicine, Queen's University, and the Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
King's College London, Guy's and St. Thomas' Hospital, London, United Kingdom
Cardiothoracic and Vascular Intensive Care Unit, Auckland City Hospital, Auckland
Medical Research Institute of New Zealand, New Zealand
Intensive Care Unit, Wellington Regional Hospital and Medical Research Institute of New Zealand, Wellington, New Zealand
Division of Nephrology, Bone and Mineral Metabolism, University of Kentucky, Lexington
University College Dublin Clinical Research Centre at St. Vincent's University Hospital, Dublin
Division of Nephrology, University of Pittsburgh, and Veterans Affairs Pittsburgh Healthcare System, Pittsburgh
Department of Intensive Care, University of Helsinki, and Helsinki University Hospital, Helsinki Hospital de Clínicas de Porto Alegre, Porto Alegre, Brazil
Department of Anesthesiology, Intensive Care and Pain Medicine, University Hospital Münster, Münster, Germany
Issue Date: Jul-2020
Date: 2020-07
Publication information: The New England Journal of Medicine 2020; 383(3): 240-251
Abstract: Acute kidney injury is common in critically ill patients, many of whom receive renal-replacement therapy. However, the most effective timing for the initiation of such therapy remains uncertain. We conducted a multinational, randomized, controlled trial involving critically ill patients with severe acute kidney injury. Patients were randomly assigned to receive an accelerated strategy of renal-replacement therapy (in which therapy was initiated within 12 hours after the patient had met eligibility criteria) or a standard strategy (in which renal-replacement therapy was discouraged unless conventional indications developed or acute kidney injury persisted for >72 hours). The primary outcome was death from any cause at 90 days. Of the 3019 patients who had undergone randomization, 2927 (97.0%) were included in the modified intention-to-treat analysis (1465 in the accelerated-strategy group and 1462 in the standard-strategy group). 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 survivors at 90 days, 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 patients (6.0%) in the standard-strategy group (relative risk, 1.74; 95% CI, 1.24 to 2.43). Adverse events occurred in 346 of 1503 patients (23.0%) in the accelerated-strategy group and in 245 of 1489 patients (16.5%) in the standard-strategy group (P<0.001). Among critically ill patients with acute kidney injury, an accelerated renal-replacement strategy was not associated with a lower risk of death at 90 days than a standard strategy. (Funded by the Canadian Institutes of Health Research and others; STARRT-AKI number, NCT02568722.).
DOI: 10.1056/NEJMoa2000741
ORCID: 0000-0002-1105-6785
Journal: The New England Journal of Medicine
PubMed URL: 32668114
Type: Journal Article
Appears in Collections:Journal articles

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