Literature

Clinical Pearls & Morning Reports


By Carla Rothaus

Published October 10, 2018

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Is mortality lower with early initiation of renal-replacement therapy as compared to delayed initiation in patients with severe acute kidney injury and septic shock?

Acute kidney injury is a frequent complication in patients hospitalized in the intensive care unit for septic shock and is associated with high mortality. In the absence of life-threatening complications of acute kidney injury, the appropriate timing of the initiation of renal-replacement therapy in patients with septic shock remains unclear. Barbar et al. conducted a randomized, controlled, open-label, multicenter trial that compared an early strategy with a delayed strategy for the initiation of renal-replacement therapy in the management of severe acute kidney injury in patients in the initial phase of septic shock. Read the latest NEJM Original Article here.

Clinical Pearls

Q: What timing for the initiation of renal-replacement therapy might be considered an “early initiation” strategy?

A: In the trial by Barbar et al., in the early-strategy group, renal-replacement therapy was initiated within 12 hours after documentation of failure-stage acute kidney injury.

Q: What timing for the initiation of renal-replacement therapy might be considered a “delayed initiation” strategy?

A: Patients assigned to the delayed-strategy group in the trial by Barbar et al. were closely monitored after randomization to detect the development of any one of the following conditions included in the criteria for emergency renal-replacement therapy: hyperkalemia (potassium level >6.5 mmol per liter), metabolic acidosis (pH <7.15), or fluid overload (extravascular fluid overload that was refractory to diuretics, with pulmonary edema). If any of these conditions occurred, renal-replacement therapy was initiated as soon as possible. If none of these conditions occurred, renal-replacement therapy was initiated in this group 48 hours after the diagnosis of acute kidney injury.

Morning Report Questions

Q: Is mortality lower with early initiation of renal-replacement therapy as compared to delayed initiation in patients with severe acute kidney injury and septic shock?

A: In the trial by Barbar et al., the early initiation of renal-replacement therapy did not result in lower mortality at 90 days than the delayed strategy; 138 of 239 patients (58%) in the early-strategy group died and 128 of 238 patients (54%) in the delayed-strategy group died (P=0.38). Further stratification according to center and adjustment for preexisting chronic renal failure and exposure to nephrotoxic agents did not change the results. There were no significant differences between the groups in the other secondary outcomes, namely mortality at 28 days and 180 days, number of days free of mechanical ventilation and vasopressors, and length of ICU and hospital stay.

Q: In the trial by Barbar et al., what percentage of patients in the delayed initiation group did not ultimately require renal-replacement therapy?

A: There was less use of renal-replacement therapy in the delayed-strategy group; 38% of patients did not undergo renal-replacement therapy (75% of these patients had spontaneous improvement in renal function).

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