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Article Dans Une Revue New England Journal of Medicine Année : 2016

Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit

1 CHU Tenon [AP-HP]
2 Service de Réanimation Médico-Chirurgicale [Avicenne]
3 BIOSPIM - Département de Biostatistique, Santé Publique et Information Médicale [CHU Pitié-Salpêtrière]
4 SU - Sorbonne Université
5 Service d'anesthésie-réanimation SAMU94-SMUR94 [Mondor]
6 SBIM - Service de biostatistique et information médicale de l’hôpital Saint Louis (Equipe ECSTRA)
7 Medical ICU, Avenue Albert Raymond, Saint-Priest en Jarez 42270, France
8 Centre Hospitalier René Dubos [Pontoise]
9 Centre Hospitalier Sud Francilien
10 HIFIH - Hémodynamique, Interaction Fibrose et Invasivité tumorales Hépatiques
11 Service de soins intensifs [CHU Rouen]
12 DHU A-TVB - Réanimation Médicale [CHU Henri Mondor - APHP]
13 Unité de soins intensifs [Clermont Ferrand]
14 Service de Réanimation Polyvalente - CHR d’Orleans
15 CHU Pitié-Salpêtrière [AP-HP]
16 CHRU Lille - Centre Hospitalier Régional Universitaire [Lille]
17 INSERM UMRS-1144, Université Paris Cité, Réanimation Médicale et Toxicologique, Hôpital Lariboisière
18 Hôpital Victor Dupouy
19 URMITE - Unité de Recherche sur les Maladies Infectieuses et Tropicales Emergentes
20 APHM - Assistance Publique - Hôpitaux de Marseille
21 MP3CV - Mécanismes physiopathologiques et conséquences des calcifications vasculaires - UR UPJV 7517
22 CHU Amiens-Picardie
23 HCL - Hospices Civils de Lyon
24 CHU Pointe-à-Pitre/Abymes [Guadeloupe]
25 EEM - Ecologie et Evolution des Microorganismes
26 IAME (UMR_S_1137 / U1137) - Infection, Anti-microbiens, Modélisation, Evolution
27 AKIKI Study Group - Artificial Kidney Initiation in Kidney Injury Study Group
Alexandre Boyer
  • Fonction : Auteur
Philippe Markowicz
  • Fonction : Auteur


BACKGROUND The timing of renal-replacement therapy in critically ill patients who have acute kidney injury but no potentially life-threatening complication directly related to renal failure is a subject of debate. METHODS In this multicenter randomized trial, we assigned patients with severe acute kidney injury (Kidney Disease: Improving Global Outcomes [KDIGO] classification, stage 3 [stages range from 1 to 3, with higher stages indicating more severe kidney injury]) who required mechanical ventilation, catecholamine infusion, or both and did not have a potentially life-threatening complication directly related to renal failure to either an early or a delayed strategy of renal-replacement therapy. With the early strategy, renal-replacement therapy was started immediately after randomization. With the delayed strategy, renal-replacement therapy was initiated if at least one of the following criteria was met: severe hyperkalemia, metabolic acidosis, pulmonary edema, blood urea nitrogen level higher than 112 mg per deciliter, or oliguria for more than 72 hours after randomization. The primary outcome was overall survival at day 60. RESULTS A total of 620 patients underwent randomization. The Kaplan-Meier estimates of mortality at day 60 did not differ significantly between the early and delayed strategies; 150 deaths occurred among 311 patients in the early-strategy group (48.5%; 95% confidence interval [CI], 42.6 to 53.8), and 153 deaths occurred among 308 patients in the delayed-strategy group (49.7%, 95% CI, 43.8 to 55.0; P = 0.79). A total of 151 patients (49%) in the delayed-strategy group did not receive renal-replacement therapy. The rate of catheter-related bloodstream infections was higher in the early-strategy group than in the delayed-strategy group (10% vs. 5%, P = 0.03). Diuresis, a marker of improved kidney function, occurred earlier in the delayed-strategy group (P<0.001). CONCLUSIONS In a trial involving critically ill patients with severe acute kidney injury, we found no significant difference with regard to mortality between an early and a delayed strategy for the initiation of renal-replacement therapy. A delayed strategy averted the need for renal-replacement therapy in an appreciable number of patients.

Dates et versions

hal-03577876 , version 1 (16-02-2022)



Stephane Gaudry, David Hajage, Frederique Schortgen, Laurent Martin-Lefevre, Bertrand Pons, et al.. Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit. New England Journal of Medicine, 2016, 375 (2), pp.122-133. ⟨10.1056/NEJMoa1603017⟩. ⟨hal-03577876⟩
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