Background
The timing of RRT initiation and outcome: an elephant touched by blind men?
Author (year) | ICU setting | RRT modality | Inclusion criteria | Exclusion criteria |
n
| End points |
---|---|---|---|---|---|---|
Randomized controlled trials | ||||||
Zarbock 2016 [24] | Predominantly surgical | CVVH | KDIGO stage 2 AKI | eGFR < 30 ml/min/1.73 m2, previous RRT, AKI caused by permanent occlusion of renal artery or surgery, GN, IN, HUS, AIDS, HRS, pregnancy | 231 | 30-day, 60-day and 90-day mortality |
Gaudry 2016 [23] | Mixed | Mixed | Ischemic or toxic AKI and receiving MV, catecholamine infusion or both, and KDIGO stage 3 AKI | BUN > 112 mg/dl, sK > 6.0 mmol/L, pH < 7.15, acute pulmonary edema | 619 | 30-day and 60-day mortality |
Prospective cohort studies | ||||||
Sabater 2009 [14] | Medical | CVVH | N/A | N/A | 148 | In-hospital mortality |
Shiao 2009 [15] | Surgical | CRRT/SLED/IHD | Postoperative AKI requiring RRT in ICU (s/p major abdominal surgery) | Age < 18 years; ICU stay < 2 days; RRT started before surgery; no abdominal surgery; renal transplant | 98 | In-hospital mortality |
Retrospective cohort studies | ||||||
Chou 2011 [16] | Medical | CRRT/ SLED | Septic AKI s/p acute RRT | Age <18 years; ICU stay < 2 days; RRT < 2 days | 370 | In-hospital mortality |
Wu 2012 [17] | Surgical | CRRT | (1) AKI with sK > 6.0 meq/L, (2) metabolic acidosis (sHCO3 < 12 meq/L), (3) pulmonary edema refractory to diuretics, or (4) oliguria with progressive azotemia, especially in hemodynamically unstable patients | N/A | 73 | 60-day and 90-day mortality |
Boussekey 2012 [18] | Mixed | N/A | ICU patients in need of RRT | N/A | 110 | In-hospital mortality |
Hu 2013 [19] | Mixed | CRRT | AKI with CRRT | CKD | 52 | In-hospital mortality |
Shum 2013 [20] | Medical | CRRT | Septic AKI | Cardiothoracic surgery, transplant surgery, and burns | 120 | In-hospital mortality |
Leite 2013 [21] | Mixed | SLED | ICU patients on acute RRT | CKD | 150 | In-hospital mortality |
Suzuki 2013 [22] | Mixed | CRRT | AKI with CRRT | N/A | 189 | In-hospital mortality |
The AKIKI and ELAIN trials: any solace?
AKIKI trial [23] | ELAIN trial [24] | |
---|---|---|
Study design | Multicenter (31 ICUs in France): randomized, unblinded | Single center (one ICU in Germany): randomized, unblinded |
Patient characteristics and number | Predominantly medical patients (79%); n = 620 (from 5528 screened patients (11%)) | Predominantly postsurgical patients (97%); n = 231 (from 604 screened patients (38%)) |
Age at enrollment (years) | 66.1a
| 67.0a
|
SOFA score at enrollment | 10.9a
| 15.8a
|
Septic shock at enrollment (%) | 66.7 | 32.0 |
Enrollment criteria | ICU patients, ≧18 years old; KDIGO stage 3 AKI; at least one of the following: MV, catecholamine need | ICU patients, 18–90 years old; KDIGO stage 2 AKI; plasma NGAL > 150 ng/ml; at least one of the following: severe sepsis, catecholamine need, nonrenal organ dysfunction, fluid overload |
Criteria for RRT in EG | KDIGO stage 3 AKI (within 6 h) | KDIGO stage 2 AKI (within 8 h) |
Criteria for RRT in DG | Any of the following: BUN > 112 mg/dl, sK > 6 mEq/L, pH < 7.15, lung edema, oliguria > 72 h | KDIGO stage 3 AKI or any of the following (within 12 h): BUN > 100 mg/dl, sK > 6 mEq/L, sMg > 8 mEq/L, organ edema, U/O < 200 ml/h |
SCr at RRT (mg/dl) | 3.3 (EG) vs 5.3 (DG)a
| 1.9 (EG) vs 2.4 (DG)a
|
Time to RRT (h) | 2.0 (EG) vs 57.0 (DG)b, c
| 6.0 (EG) vs 25.5(DG)b, d
|
Initial modality | 55.0% IHD, 45.0% CRRT (modality not available) | 100.0% CRRT (CVVHDF) |
Receipt of RRT | EG (98.0%) > DG (51.0%) (p < 0.001) | EG (100.0%) > DG (91.0%) (p < 0.001) |
Primary endpoint | 60-day mortality EG (48.5%) ≒ DG (49.7%) (p = 0.79) | 90-day mortality EG (39.3%) < DG (54.7%) (p = 0.03) → EG better |
Other outcomes | Catheter-related-infection: EG (10.0%) > DG (5.0%) (p = 0.03) → DG better | Median LOS: EG (51 days) < DG (82 days) (p < 0.001) Duration of MV: EG (126 h) < DG (181 h) (p = 0.002) → EG better |
Special remarks | 60-day mortality: all EG (48.5%) ≒ DG (49.7%); DG/RRT(–) (37.1%) < EG (48.5%) < DG/RRT(+) (61.8%) |