Renal

1. EARLY VS LATE
RRT

2. Early inititaion
 Pros
 Better control of fluid &electrolyte status,
acid-base homeostasis
 Removal of uremic toxins
 Prevention of complications such as
gastric haemorhage & metabolic
encephalopathy
 Cons
 Mechanical complications
 Bio-incompatibility
 Anticoagulant related
 Hypotension, delayed renal recovery
 Drug clearance & overall cost
1. Gibeneyn, Hostee, Burdmannae etal. Timing of initiation and discontinuation of renal replacement therapy in
aki: un-answered key questions. Clin J Am Soc Nephrol 2008;3:876-80
2. Bagshaw sm, uchino s, bellomo r, et al. timing of renal replacement therapy and clinical outcomes in critically
ill patients with severe aki. J Crit Care 2009;24:129-40
3. Vaara st, reikikainen m, wald r, Bagshaw sm, pettila v. timing of rrt based on the presence of conventional
indications. Clin J Am Soc Nephrol 2014;9:1577-85

4. AKIKI TRIAL

5. AKIKI Inclusion criteria
 Adults
 ICU with AKI that was compatible with a diagnosis of ATN in the context of ischemic or
toxic injury
 Invasive mechanical ventilation
 Vasopressors
 Or both
 KDIGO stage 3 AKI

6. Categorization
Early group
 AKI stage 3
 Mechanical ventilation or vasopressors
or both
 No potentially life threatening
complication directly related to renal
failure
Delayed group
 Oliguria more than 72 hrs after
randomization
 BUN >112 mg/dl
 Severe hyperkalemia
 Severe metabolic acidosis
 Pulmonary edema

7. Interventions- each study site was free
to decide
 Method of RRT (intermittent or continuous)
 Duration of RRT
 Interval between sessions
 Device settings
 Antoagulation

8. Discontinuation of RRT
 Considered
 Urine output >550/24 hr
 Highly recommended
 Urine output >1000 ml/24 with no diuretics
 Urine output >2000 ml/24 with diuretics
 Mandatory
 Urine output sufficient to decrease in serum creatinine

9. AKIKI trial
311 for early
group
308 delayed group
619 underwent
randomisation
5528 pts eligible
for inclusion

10. KDIGO 3 AKI
Delayed RRT
Conventional
indications
>72 hr after
KDIGO 3 AKI
BUN >112 mg/dl
Early RRT RRT < 12 hr

11. Result
 No difference in 60 day mortality
 More RRT free days in delayed group

13. ELAIN
JAMA 2016

14. Objective
 To determine whether early initiation of RRT in patients who are critically ill patients with
AKI reduces 90 day all cause mortality.

15. Study design
 Single centre RCT
 University Hospital in Germany
 231 critically ill patients with AKI KDIGO 2
 Plasma NGAL level higher than 150 pg/ml
 Duration: Aug 2013- June 2015

16. Interventions
 Early- within 8 hrs of diagnosis of AKI stage 2
 Late- within 12 hrs of diagnosis of AKI stage 3

17. Inclusion in ELAIN
 KDIGO stage 2 AKI
 Plasma NGAL >150 pg/ml
 At least one of the following
 Severe sepsis
 Vasopressors
 Refractory fluid overload
 Non renal organ dysfunction (SOFA >2)
 Age 18-90 years

18. ELAIN trial
KDIGO AKI 2
Early RRT RRT <8hr
Delayed RRT
<12 hr after
AKI 3
Conventional
indications

19. ELAIN patient flow

21. RRT in ELAIN
Identical settings were used in both groups
CVVHDF in all patients
Replacement fluid- Pre filter
Effluent flow- 30 ml/kg/hr
Blood flow >110ml/min
Regional anticoagulation- Citrate

22. ELAIN
Outcome

25. ELAIN Conclusion
 Potential benefits of earlier initiation are attributable to
 More rapid metabolic or uremic control
 More effective prevention and management of fluid overload
 RRT before the onset of severe AKI may attenuate
 Kidney specific and non kidney organ injury
 Due to acidemia, uremia, fluid overload and systemic inflammation
 Limitations
 Single centre RCT
 95% patients recruited were surgical patients (limited generalizability)

27. IDEAL-ICU
NEJM.2018

28. Inclusion criteria
 >18 years of age
 ICU with septic shock
 AKI with failure stage of RIFLE criteria:
 Oliguria (UO <0.3 ml/kg/hr. >24hrs)
 Anuria for >12 hr. or creatinine 3 times the baseline

29. IDEAL ICU TRIAL
AKI- RIFLE,
failure stage
Early RRT RRT <12 hr
Delayed RRT
>48 hr after,
AKI-Failure
stage
Conventional
indications

34. STARRT AKI Trial
• NEJM.2020 (2015-19)
• 168 hospitals in 15 countries
• 11,852 patients met provisional eligibility criteria
• 3019 patients were included

35. Inclusion criteria
 18 Years or older admitted to an ICU
 KDIGO AKI 2 or 3

40. Thank you