Accelerated Renal-Replacement Therapy Not Beneficial for Severe Kidney Injuries

July 24, 2020
Kenny Walter

Kenny Walter is an editor with HCPLive. Prior to joining MJH Life Sciences in 2019, he worked as a digital reporter covering nanotechnology, life sciences, material science and more with R&D Magazine. He graduated with a degree in journalism from Temple University in 2008 and began his career as a local reporter for a chain of weekly newspapers based on the Jersey shore. When not working, he enjoys going to the beach and enjoying the shore in the summer and watching North Carolina Tar Heel basketball in the winter.

More than 40% of critically ill patients died within 90 days regardless of timing of renal-replacement therapy.

Sean M. Bagshaw, MD

Acute kidney injuries (AKI) are common for critically ill patients and often lead to renal-replacement therapy. However, the most effective timing for the initiation of this therapy is unknown.

An international research team hailing from 5 different countries, led by Sean M. Bagshaw, MD, the Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, conducted a multinational, randomized, controlled trial examining critically ill patients with severe acute kidney injuries and what the optimal timing for renal-replacement therapy was.

Each patient was randomly assigned to receive an accelerated strategy of renal-replacement therapy where therapy was initiated within 12 hours following the patient meeting eligibility criteria or a standard strategy where renal-replacement therapy was discouraged unless conventional indications developed or acute kidney injury persisted for more than 72 hours.

The investigators sought a primary outcome of death from any cause at 90 days.

A total of 3019 patients were randomized, 2927 (97.0%) of which were included in the modified intention-to-treat analysis (1465 in the accelerated-strategy group and 1462 in the standard-strategy group).

Renal-replacement therapy was performed in 1418 (96.8%) of individuals in the accelerated-strategy group and 903 (61.8%) of patients in the standard-strategy group. At the conclusion of the 90 day period, 643 patients (43.9%) in the accelerated-strategy group and 639 (43.7%) participants in the standard-strategy group had died (RR, 1.00; 95% CI, 0.93-1.09; P = 0.92).

For the survivors, 85 (10.4%) patients continued dependence at 90 days on renal-replacement therapy and 49 (6.0%) in the standard-strategy group (RR, 1.74; 95% CI, 1.24-2.43).

The investigators also identified adverse events occurring in 346 (23.0%) of individuals in the accelerated-strategy group and 245 (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,” the authors wrote.

Earlier this year, researchers found proteinuria levels following an acute kidney injury could help predict the future risk of the loss of renal function.

A team from several different institutions, led by Chi-yuan Hsu, MD, Division of Nephrology, University of California School of Medicine, San Francisco, found that more widespread quantification of proteinuria after a hospitalized acute kidney injury should be considered to better evaluate the risk of future kidney disease progression.

In a matched cohort study involving 1538 patients, half of which have an acute kidney injury during hospitalization, the investigators found higher urine albumin-to-creatinine ratio (ACR) quantified 3 months following hospitalization discharge with an AKI was linked to an increased risk of kidney disease progression and served as a risk discriminator.

Higher post-AKI urine ACR level was associated with increased risk of kidney disease progression (HR, 1.53 for each doubling; 95% CI, 1.45-1.62), and urine ACR measurement was a strong discriminator for future kidney disease progression (C statistic, .82).

The study, “Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury,” was published in the New England Journal of Medicine.