A talk by Johan Mårtensson at the 2017 meeting of the Scandinavian Society of Anaestesiology and Intensive Care Medicine. All available content from SSAI2017: https://scanfoam.org/ssai2017/ Delivered in collaboration between scanFOAM, SSAI & SFAI.

1. Earlier vs Later Renal Replacement
Therapy (RRT)
Johan Mårtensson

2. Conflict of interest: None

3. Time for RRT? –Yes!
Mr. Jones, 58 yr
Day 4 in ICU
Severe sepsis
Fluid balance ++++
FiO2 0.7
S-creatinine 540 µmol/L
Urea 40 mmol/L
S-K+ 6.2 mmol/L
Urine output 20 mL/hour
(lasix infusion 40 mg/hr)

4. ”Late” RRT
”Conventional” or ”absolute” indications for RRT in AKI:
• Refractory hyperkalemia (e.g. K+ >6)
• Refractory acidemia & metabolic acidosis (e.g. pH <7.2)
• Refractory pulmonary edema due to fluid overload
• Uremic complications (e.g. bleeding, pericarditis)
• Overdose/toxicity from a dialyzable drug/toxin

6. Contemporary AKI staging
KDIGO
stage
Plasma creatinine Urine output
1 1.5-2 times baseline
OR
>26.5 µmol/l increase
<0.5 ml/kg/h for 6-12 h
2 2.0-2.9 times baseline <0.5 ml/kg/h for ≥12 h
3 3.0 times baseline
OR
Increase to ≥354 µmol/l
<0.3 ml/kg/h for ≥24 h
OR
Anuria for ≥12 h
the Kidney Disease Improving Global
Outcomes (KDIGO) guidelines

7. The AKIKI trial

8. AKIKI setup
620 pts, 31 ICUs
• KDIGO stage 3 AKI
• Mechanical ventilation and/or catecholamine infusion
• No absolute indication
Early Group (n=311)
Start RRT immediately
Late Group (n=308)
Start RRT if:
Absolute indication OR
Oliguria >72 hrs

9. AKIKI treatmentRandomisation
2 hours
57 h
0
20
40
60
80
100%receivingRRT
Early Late
49% no RRT
51% RRT
≥1 absolute indication
(82%)
Oliguria >72 h (18%)

10. AKIKI 60-day mortality
P=0.79
0
20
40
6060-daymortality,%
Early Late

11. AKIKI secondary outcomes
P=0.12
0
2
4
6
8
10
DependenceonRRTday60,%
Early Late
P=0.03
0
5
10
15
20
Catheter-relatedbloodstreaminfection,%
Early Late

12. The ELAIN trial

13. ELAIN setup
231 pts (mainly post-surgical), single-center
• KDIGO stage 2 AKI
• Plasma Neutrophil gelatinase-associated lipocalin (NGAL) >150 ng/ml
• Any of the following:
• Severe sepsis
• Vasoactive support
• Fluid overload
• Worsening SOFA score
Early Group (n=112)
RRT within 8 h from KDIGO 2
Late Group (n=119)
RRT within 12 h from KDIGO 3 OR
Absolute indication

14. ELAIN treatment
Randomisation 6 hours
26 hours
0
20
40
60
80
100
%receivingRRT
Early Late
9% no RRT
91% RRT
-KDIGO 3 (84%)
-Absolute
indication (16%)

15. ELAIN 90-day mortality
P=0.03
0
20
40
60
90-daymortality,%
Early Late

16. ELAIN renal recovery
P=0.62
0
20
40
60
80
100
meanofrecovery90surv
Early Late
Survivors
P=0.02
0
20
40
60
80
100
Renalrecoveryday90,%
Early Late
All patients

18. Other factors affecting decision
making
• Anticipation of worsening kidney function
• Worsening nonrenal organ dysfunction
• Expected high solute burden (e.g. tumor lysis
syndrome)
• Facilitate other supportive measures (nutrition,
drugs, other fluids)
• Perception of benefit

19. *
* Treating clinician must confirm clinical equipoise

20. Take-home message
• No strong evidence that ”early” RRT will
improve outcomes
• ”Early” RRT may expose some patients to
unnecessary treatment
• Timing based on patient characteristics, illness
severity and trends in
physiology/biochemistry