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Original Investigation | Caring for the Critically Ill Patient

Effect of Early vs Delayed Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients With Acute Kidney Injury The ELAIN Randomized Clinical Trial

Alexander Zarbock, MD1; John A. Kellum, MD2; Christoph Schmidt, MD1; Hugo Van Aken, MD1; Carola Wempe, PhD1; Hermann Pavenstädt, MD3; Andreea Boanta, MD1; Joachim Gerß, PhD4; Melanie Meersch, MD1
[+] Author Affiliations
1Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Germany
2Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pennsylvania
3Department of Internal Medicine D, University Hospital Münster, Germany
4Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany
JAMA. 2016;315(20):2190-2199. doi:10.1001/jama.2016.5828.
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Importance  Optimal timing of initiation of renal replacement therapy (RRT) for severe acute kidney injury (AKI) but without life-threatening indications is still unknown.

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

Design, Setting, and Participants  Single-center randomized clinical trial of 231 critically ill patients with AKI Kidney Disease: Improving Global Outcomes (KDIGO) stage 2 (≥2 times baseline or urinary output <0.5 mL/kg/h for ≥12 hours) and plasma neutrophil gelatinase–associated lipocalin level higher than 150 ng/mL enrolled between August 2013 and June 2015 from a university hospital in Germany.

Interventions  Early (within 8 hours of diagnosis of KDIGO stage 2; n = 112) or delayed (within 12 hours of stage 3 AKI or no initiation; n = 119) initiation of RRT.

Main Outcomes and Measures  The primary end point was mortality at 90 days after randomization. Secondary end points included 28- and 60-day mortality, clinical evidence of organ dysfunction, recovery of renal function, requirement of RRT after day 90, duration of renal support, and intensive care unit (ICU) and hospital length of stay.

Results  Among 231 patients (mean age, 67 years; men, 146 [63.2%]), all patients in the early group (n = 112) and 108 of 119 patients (90.8%) in the delayed group received RRT. All patients completed follow-up at 90 days. Median time (Q1, Q3) from meeting full eligibility criteria to RRT initiation was significantly shorter in the early group (6.0 hours [Q1, Q3: 4.0, 7.0]) than in the delayed group (25.5 h [Q1, Q3: 18.8, 40.3]; difference, −21.0 [95% CI, −24.0 to −18.0]; P < .001). Early initiation of RRT significantly reduced 90-day mortality (44 of 112 patients [39.3%]) compared with delayed initiation of RRT (65 of 119 patients [54.7%]; hazard ratio [HR], 0.66 [95% CI, 0.45 to 0.97]; difference, −15.4% [95% CI, −28.1% to −2.6%]; P = .03). More patients in the early group recovered renal function by day 90 (60 of 112 patients [53.6%] in the early group vs 46 of 119 patients [38.7%] in the delayed group; odds ratio [OR], 0.55 [95% CI, 0.32 to 0. 93]; difference, 14.9% [95% CI, 2.2% to 27.6%]; P = .02). Duration of RRT and length of hospital stay were significantly shorter in the early group than in the delayed group (RRT: 9 days [Q1, Q3: 4, 44] in the early group vs 25 days [Q1, Q3: 7, >90] in the delayed group; P = .04; HR, 0.69 [95% CI, 0.48 to 1.00]; difference, −18 days [95% CI, −41 to 4]; hospital stay: 51 days [Q1, Q3: 31, 74] in the early group vs 82 days [Q1, Q3: 67, >90] in the delayed group; P < .001; HR, 0.34 [95% CI, 0.22 to 0.52]; difference, −37 days [95% CI, −∞ to −19.5]), but there was no significant effect on requirement of RRT after day 90, organ dysfunction, and length of ICU stay.

Conclusions and Relevance  Among critically ill patients with AKI, early RRT compared with delayed initiation of RRT reduced mortality over the first 90 days. Further multicenter trials of this intervention are warranted.

Trial Registration  German Clinical Trial Registry Identifier: DRKS00004367

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Figure 1.
Flow of Patients Through the ELAIN Trial

ELAIN indicates Early vs Late Initiation of Renal Replacement Therapy in Critically Ill Patients With Acute Kidney Injury; KDIGO, Kidney Disease: Improving Global Outcomes; RRT, renal replacement therapy; CKD, chronic kidney disease; GFR, glomerular filtration rate; AKI, acute kidney injury; SOFA, sepsis-related organ failure assessment; NGAL, neutrophil gelatinase–associated lipocalin.

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Figure 2.
Mortality Probability Within 90 Days After Study Enrollment for Patients Receiving Early and Delayed Initiation of Renal Replacement Therapy (RRT)

KDIGO indicates Kidney Disease: Improving Global Outcomes. In the delayed group, 18 patients had an absolute indication for RRT. The median (quartile 1 [Q1], quartile 3 [Q3]) duration of follow-up was 90 days (Q1, Q3: 90, 90) in the early group and 90 days (Q1, Q3: 90, 90) in the delayed group. The vertical ticks indicate censored cases.

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