QW21-January-2025 – Nephro Critical Care Society

QW21-January 2025

Question 1: Select each option to validate with explanations

The initiation of renal replacement therapy (RRT) in critically ill patients remains a topic of debate. The ELAIN, AKIKI, STARRT-AKI, and IDEAL ICU trials sought to identify the best timing for starting this therapy in patients with acute kidney injury. The results of these studies have provided valuable insights, yet they highlight the complexity of managing acute kidney injury (AKI) in critical care settings.

Question: Select the INCORRECT statement about the four trials mentioned above.

A. Each trial examined different criteria for starting RRT, with varying patient populations and clinical settings, thus complicating the extrapolation of results.

B. The AKIKI trial suggested that a more conservative approach could be just as effective, if not better, in terms of survival rates when initiated later in the course of illness.

C. The STARRT-AKI trial emphasized the importance of considering individual patient factors, advocating for a more tailored approach to RRT initiation.

D. The findings from the IDEAL ICU trial raised questions about the thresholds used to initiate therapy, suggesting that not all patients with AKI require immediate intervention.

E. All trials demonstrated no survival benefit of early initiation of RRT.

Wrong Answer: A. Each trial examined different criteria for starting RRT, with varying patient populations and clinical settings, thus complicating the extrapolation of results.

Wrong Answer: B. The AKIKI trial suggested that a more conservative approach could be just as effective, if not better, in terms of survival rates when initiated later in the course of illness.

Wrong Answer: C. The STARRT-AKI trial emphasized the importance of considering individual patient factors, advocating for a more tailored approach to RRT initiation.

Wrong Answer: D. The findings from the IDEAL ICU trial raised questions about the thresholds used to initiate therapy, suggesting that not all patients with AKI require immediate intervention.

Right Answer: E. All trials demonstrated no survival benefit of early initiation of RRT.

Explaination:
E. All trials demonstrated no survival benefit of early initiation of RRT. This statement is incorrect. The ELAIN trial showed improved 90-day mortality with early RRT initiation (39.3% vs 54.7% for the delayed group). However, three other trials found no mortality benefit from early RRT initiation. The AKIKI trial specifically supported delayed initiation, showing a reduced need for RRT without compromising mortality (option B). Each trial examined different criteria for starting RRT (see table 1), with varying patient populations and clinical settings, thus complicating the extrapolation of results (B).
Table 1. Criteria for starting RRT, patient populations, and clinical settings in four major trials on timing of RRT in AKI patients

Kinetic Glomerular Filtration Rate (kGFR) is an advanced method for assessing kidney function, particularly valuable in acute settings where rapid changes in renal performance occur. Traditional GFR estimation methods often assume steady-state conditions, which can lead to inaccuracies during acute kidney injury (AKI) or other dynamic renal situations. kGFR addresses this limitation by incorporating the rate of change in serum creatinine levels, providing a more responsive measure of renal function during non-steady-state conditions. KGFR is a valuable tool in the early identification of patients at risk for worsening kidney function and adverse outcomes. By providing a dynamic assessment of renal function, KeGFR enables clinicians to make more informed decisions regarding patient management, potentially leading to improved prognoses.
In the STARRT-AKI Trial, patients in the accelerated arm were required to start CRRT within 12 hours of randomization, with an average initiation time of 6 hours. The trial demonstrated no benefit from this approach, advocating for a tailored strategy to initiate RRT (Table 2). Additionally, early dialysis may increase the risk of long-term dependence on renal replacement therapy, suggesting a potential risk of dialysis-induced kidney injury for these patients.

Table 2. Limitations and conclusions of four major trials on timing of RRT in AKI patients

Reference:

1. Bagshaw, S.M., Lamontagne, F., Joannidis, M. et al. When to start renal replacement therapy in critically ill patients with acute kidney injury: comment on AKIKI and ELAIN. Crit Care 20, 245 (2016). https://doi.org/10.1186/s13054-016-1424-0
2. IDEAL-ICU Trial Investigators and the CRICS TRIGGERSEP Network. Timing of Renal-Replacement Therapy in Patients with Acute Kidney Injury and Sepsis. N Engl J Med. 2018 Oct 11;379(15):1431-1442. doi: 10.1056/NEJMoa1803213. PMID: 30304656.
3. Starrt-Aki Investigators. Timing of initiation of renal-replacement therapy in acute kidney injury. New England Journal of Medicine. 2020 Jul 16;383(3):240-51.