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

Stephane Gaudry 1, 2 David Hajage 3, 4 Frederique Schortgen 5 Laurent Martin-Lefevre 6 Bertrand Pons 7 Eric Boulet 8 Alexandre Boyer Guillaume Chevrel 9 Nicolas Lerolle 10 Dorothee Carpentier 11 Nicolas De Prost 12 Alexandre Lautrette 13 Anne Bretagnol 14 Julien Mayaux 15 Saad Nseir 16 Bruno Megarbane 17 Marina Thirion 18 Jean-Marie Forel 19, 20 Julien Maizel 21, 22 Hodane Yonis 23 Philippe Markowicz Guillaume Thiery 24 Florence Tubach 3 Jean-Damien Ricard 25 Didier Dreyfuss 2, 26 
Abstract : 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.
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Soumis le : mercredi 16 février 2022 - 18:58:00
Dernière modification le : lundi 14 novembre 2022 - 01:44:05

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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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