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EDITORIAL
Year : 2022  |  Volume : 4  |  Issue : 1  |  Page : 2

Timing for Initiating Renal Replacement Therapy in Patients with Acute Kidney Injury: Late is Better?


Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, Harbin, People's Republic of China

Date of Submission30-Oct-2021
Date of Acceptance16-Dec-2021
Date of Web Publication18-Jan-2022

Correspondence Address:
Dr. Kaijiang Yu
Department of Critical Care Medicine, The First Affiliated Hospital of Harbin Medical University, Harbin Medical University, 23 Youzheng Street, Harbin 150001, Heilongjiang Province
People's Republic of China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/JTCCM-D-21-00025

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How to cite this article:
Yu K. Timing for Initiating Renal Replacement Therapy in Patients with Acute Kidney Injury: Late is Better?. J Transl Crit Care Med 2022;4:2

How to cite this URL:
Yu K. Timing for Initiating Renal Replacement Therapy in Patients with Acute Kidney Injury: Late is Better?. J Transl Crit Care Med [serial online] 2022 [cited 2022 May 25];4:2. Available from: http://www.tccmjournal.com/text.asp?2022/4/1/2/335949



Timing for renal replacement therapy (RRT) in acute kidney injury (AKI): Delaying RRT with closely monitoring may be the better option.

Critically ill patients with AKI, many of them receive renal-replacement therapy. Hyperkalemia or metabolic acidosis and pulmonary edema unresponsive to diuretic administration are recognized criteria for RRT initiation; however, for patients without those complications, the most effective timing for the initiation of such therapy remains uncertain.

In recent years, lots of studies have focused on the timing of the initiation of RRT. The first question needs to be clarified: Is it better to initiate RRT as early as possible? Some studies showed that there was no significant difference with regard to mortality between an early and a delayed strategy for the initiation of RRT in critically ill patients with severe AKI;[1],[2] however, some patients in the delayed-strategy group did not receive RRT, and the rate of catheter-related bloodstream infections was lower in the delayed-strategy group. We can see that early strategy for the initiation of RRT is not better. The same conclusion was drawn in a review,[3] Early RRT may reduce the risk of death and may improve the recovery of kidney function in critically patients with AKI; however, the 95% confidence interval indicates that early RRT might worsen these outcomes. There was an increased risk of adverse events with early RRT.

According those results, is it better to delay the initiation of RRT? Actually, further study on timing for the initiation of RRT is needed. A meta-analysis published in Lancet[4] showed that there was no significant difference in 28-day mortality between the delayed RRT group and the early RRT group (44% vs. 43%). However, 42% of patients were allocated to the delayed RRT group, who did not receive RRT. Therefore, it made a suggestion: The timing of RRT initiation does not affect survival in critically ill patients with severe AKI in the absence of urgent indications for RRT. Delaying RRT initiation, with close patient monitoring, might lead to a reduced use of RRT, thereby saving health resources. In the same year, another study[5] got the same result. It showed that critically ill patients with AKI, an early strategy was not associated with a lower risk of death at 90 days than delayed strategy (in which RRT was discouraged unless conventional indications developed or AKI persisted for >72 h). Importantly, adverse events occurred in the early strategy group (23.0%) were higher than delayed group (16.5%). According to those results, we can see that early-strategy of RRT initiation does not confer more benefits, and delay-strategy may lead to a reduced use of RRT. Is it as late as possible? Does more-delayed initiation strategy will result in more RRT-free days?

The large international trial and individual patient-data meta-analysis clearly demonstrated that RRT should not be initiated in emergency situation. The most difficulty remains in defining the appropriate duration of the postponement of RRT. In 2021, the latest study[6] on delayed strategy and more-delayed strategy (RRT initiation was postponed until mandatory indication (noticeable hyperkalemia or metabolic acidosis or pulmonary edema) or until blood urea nitrogen concentration reached 140 mg/dL) showed that the number of complications potentially related to AKI or to RRT were similar between those two groups, so did the median number of RRT-free days. In a multivariable analysis, the hazard ratio for death at 60 days was 1.65 with the more-delayed versus the delayed strategy. It got a suggestion: in severe AKI patients with oliguria for more than 72 h or blood urea nitrogen concentration higher than 112 mg/dL and no severe complication that would mandate immediate RRT, longer postponing of RRT initiation did not confer additional benefit and was associated with potential harm.

With the results of these large multicenter studies, we suggest that delaying RRT initiation, with closely monitoring, may be the better option and may lead to a reduced use of RRT, thereby saving health resources.

Conflicts of interest

Kaijiang Yu is the Editor-in-Chief of the journal. The article was subject to the journal's standard procedures, with peer review handled independently of these members and their research groups.



 
  References Top

1.
Gaudry S, Hajage D, Schortgen F, Martin-Lefevre L, Pons B, Boulet E, et al. Initiation strategies for renal-replacement therapy in the Intensive Care Unit. N Engl J Med 2016;375:122-33.  Back to cited text no. 1
    
2.
Barbar SD, Clere-Jehl R, Bourredjem A, Hernu R, Montini F, Bruyère R, et al. Timing of renal-replacement therapy in patients with acute kidney injury and sepsis. N Engl J Med 2018;379:1431-42.  Back to cited text no. 2
    
3.
Fayad AI, Buamscha DG, Ciapponi A. Timing of renal replacement therapy initiation for acute kidney injury. Cochrane Database Syst Rev 2018;12:CD010612.  Back to cited text no. 3
    
4.
Gaudry S, Hajage D, Benichou N, Chaïbi K, Barbar S, Zarbock A, et al. Delayed versus early initiation of renal replacement therapy for severe acute kidney injury: A systematic review and individual patient data meta-analysis of randomised clinical trials. Lancet 2020;395:1506-15.  Back to cited text no. 4
    
5.
Bagshaw SM, Wald R, Adhikari NK, Bellomo R, da Costa BR, Dreyfuss D, et al. Timing of initiation of renal-replacement therapy in acute kidney injury. N Engl J Med 2020;383:240-51.  Back to cited text no. 5
    
6.
Gaudry S, Hajage D, Martin-Lefevre L, Lebbah S, Louis G, Moschietto S, et al. Comparison of two delayed strategies for renal replacement therapy initiation for severe acute kidney injury (AKIKI 2): A multicentre, open-label, randomised, controlled trial. Lancet 2021;397:1293-300.  Back to cited text no. 6
    




 

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