The artificial kidney induces AKI? Not if we apply “kidney-protective” renal replacement therapy

Excerpt

Undoubtedly, timely and appropriate use of renal replacement therapy (RRT) has saved the lives of many who without such treatment would have succumbed to the consequences of acute kidney injury (AKI). Technological progress together with increased emphasis on multi-organ support has led, in many centres, to implementation of RRT in anticipation of absolute indications being proposed. However, this enthusiasm for “early” treatment has been tempered by investigators critical of this approach who advocate a “less is more” strategy highlighting both costs and the potential adverse effects of inappropriate therapy. Support for this approach is provided by the results of two French randomized controlled trials (AKIKI [1] and IDEAL ICU [2]) which both failed to demonstrate any benefit from earlier implementation of RRT compared to a “delayed” strategy for AKI. Indeed, many patients in the “delayed” group eventually did not receive RRT. Early initiation of RRT in both studies was based on AKI criteria (change in serum creatinine or duration of urine output) in patients with multiple organ failure, and it is no surprise that patients randomized in the more restrictive arm needed less RRT. Potential side effects of unwarranted RRT were further underlined in the AKIKI trial, with a higher incidence of catheter-related infections in the “early” group. The lack of benefit in these studies has promoted the view that RRT may be harmful and should be employed only in the face of imminently life-threatening consequences of severe renal dysfunction. While we fully agree that applying an invasive therapy when not required is highly undesirable, we feel that the suggestion that RRT is intrinsically harmful and to be avoided at all costs is overly nihilistic and neglects the important role that RRT may place in the integrated management of the patient with multi-organ failure. …