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Shedding New Light on an Old Dilemma: Two Trials Examining the Timing of Renal Replacement Therapy Initiation in Acute Kidney Injury

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What Do These Important Studies Show?

The AKIKI trial was an open-label 31-center trial in France that tested the hypothesis that a delayed strategy of RRT initiation would lead to an absolute 15% improvement in 60-day survival among critically ill patients with severe AKI.14 The investigators recruited 620 critically ill adults with KDIGO (Kidney Disease: Improving Global Outcomes) stage 3 AKI attributed to acute tubular necrosis who were being treated with either mechanical ventilation or vasopressors. They excluded patients with

How Do These Studies Compare With Prior Studies?

AKIKI and ELAIN were well-executed trials that represent important additions to our understanding of optimal triggers and circumstances for RRT initiation in AKI. By virtue of being randomized controlled trials, these were free of the biases inherent to the observational studies that have previously dominated this field. The only other randomized trials in this area were a significantly underpowered study to detect meaningful differences in patient outcomes9 and a small pilot trial that our

What Should Clinicians and Researchers Do?

The publication of 2 similarly themed trials with conflicting results will likely sustain the clinical uncertainty regarding the optimal timing of RRT initiation in AKI. The cautious clinician should avoid the temptation to embrace the trial that validates his or her current practice or cognitive biases regarding the optimal time of RRT initiation. Though both are nominally regarded as “timing trials,” AKIKI and ELAIN had fundamental differences in philosophy and design (Table 1).

The key

Acknowledgements

Support: The authors are supported by research funding from the Canadian Institute of Health Research (MOP-142296) and an unrestricted research grant provided by Baxter (IPR-139081).

Financial Disclosure: The authors are steering committee members of the ongoing STandard vs Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial (Clinicaltrials.gov NCT02568722). Drs Wald and Bagshaw have served as paid consultants and speakers for Baxter. Dr Bagshaw is the

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