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Timing of initiation of renal-replacement therapy in acute kidney injury

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Sean M. Bagshaw, Ron Wald, Neill K.J. Adhikari, Rinaldo Bellomo, Bruno R. da Costa, Didier Dreyfuss, Bin Du, Martin P. Gallagher, Stéphane Gaudry, Eric A. Hoste, François Lamontagne, Michael Joannidis, Giovanni Landoni, Kathleen D. Liu, Daniel F. McAuley, Shay P. McGuinness, Javier A. Neyra, Alistair D. Nichol, Marlies Ostermann, Paul M. Palevsky & 13 more Ville Pettilä, Jean Pierre Quenot, Haibo Qiu, Bram Rochwerg, Antoine G. Schneider, Orla M. Smith, Fernando Thomé, Kevin E. Thorpe, Suvi Vaara, Matthew Weir, Amanda Y. Wang, Paul Young, Alexander Zarbock

Original languageEnglish
Pages (from-to)240-251
Number of pages12
JournalNew England Journal of Medicine
Issue number3
Published16 Jul 2020

King's Authors


BACKGROUND Acute kidney injury is common in critically ill patients, many of whom receive renal-replacement therapy. However, the most effective timing for the initiation of such therapy remains uncertain. METHODS We conducted a multinational, randomized, controlled trial involving critically ill patients with severe acute kidney injury. Patients were randomly assigned to receive an accelerated strategy of renal-replacement therapy (in which therapy was initiated within 12 hours after the patient had met eligibility criteria) or a standard strategy (in which renal-replacement therapy was discouraged unless conventional indications developed or acute kidney injury persisted for >72 hours). The primary outcome was death from any cause at 90 days. RESULTS Of the 3019 patients who had undergone randomization, 2927 (97.0%) were included in the modified intention-to-treat analysis (1465 in the accelerated-strategy group and 1462 in the standard-strategy group). Of these patients, renal-replacement therapy was performed in 1418 (96.8%) in the accelerated-strategy group and in 903 (61.8%) in the standard-strategy group. At 90 days, death had occurred in 643 patients (43.9%) in the accelerated-strategy group and in 639 (43.7%) in the standard-strategy group (relative risk, 1.00; 95% confidence interval [CI], 0.93 to 1.09; P=0.92). Among survivors at 90 days, continued dependence on renal-replacement therapy was confirmed in 85 of 814 patients (10.4%) in the accelerated-strategy group and in 49 of 815 patients (6.0%) in the standard-strategy group (relative risk, 1.74; 95% CI, 1.24 to 2.43). Adverse events occurred in 346 of 1503 patients (23.0%) in the accelerated-strategy group and in 245 of 1489 patients (16.5%) in the standard-strategy group (P<0.001). CONCLUSIONS Among critically ill patients with acute kidney injury, an accelerated renal-replacement strategy was not associated with a lower risk of death at 90 days than a standard strategy.

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