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Comment & Response |

Timing of Initiation of Renal Replacement Therapy in Critically Ill Patients With Acute Kidney Injury FREE ONLINE FIRST

Christophe Vinsonneau, MD, MSc1; Mehran Monchi, MD1
[+] Author Affiliations
1Intensive Care Unit, Marc Jacquet Hospital, Melun, France
JAMA. Published online September 20, 2016. doi:10.1001/jama.2016.11329
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Published online

To the Editor The Early vs Late Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients With Acute Kidney Injury (ELAIN) trial reported decreased mortality with early vs delayed renal replacement therapy (RRT) initiation in critically ill patients with acute kidney injury (AKI).1 In contrast, the Artificial Kidney Initiation in Kidney Injury (AKIKI) trial found no mortality difference with early vs delayed strategies.2 However, the design of the 2 studies was different. In the AKIKI trial, late initiation was based on typical absolute criteria (hyperkalemia, metabolic acidosis, pulmonary edema, severe oliguria) compared with a time-frame initiation (<12 hours of reaching Kidney Disease: Improving Global Outcomes [KDIGO] stage 3 AKI) in the ELAIN trial. The case-mix in the 2 studies was different. In the ELAIN study, the population was mostly postoperative patients with approximately 50% having had cardiac surgery, whereas in the AKIKI study, the population was mainly medical (around 80% had sepsis).

However, the difference in mortality at 60 days after randomization between the early and delayed strategies was not statistically significant in either study. The effect on mortality in the ELAIN study did not reach significance until day 90.

The results of the ELAIN trial raise some concerns. The mortality in the 2 groups appears low given the severity scores (Acute Physiology and Chronic Health Evaluation II and Sequential Organ Failure Assessment [SOFA]), which predict a mortality as high as 70%. In addition, the difference in mortality at day 90 seems large (54.7% in the delayed group vs 39.3% in the early group; mean reduction, −15.4% [95% CI, −28.1% to −2.6%]). To date, no intervention in the intensive care unit has shown such a positive effect, and it appears improbable that early vs late RRT could achieve this benefit. Even more surprising is the very late effect on mortality. The difference did not become statistically significant until day 90, and the 2 survival curves separated only after the first 10 days. Other factors may explain the results.

Editor’s Note: This letter was inadvertently omitted from the September 20 issue.

ARTICLE INFORMATION

Section Editor: Jody W. Zylke, MD, Deputy Editor.

Corresponding Author: Christophe Vinsonneau, MD, MSc, Intensive Care Unit, Marc Jacquet Hospital, 2 rue freteau de peny, 77000 Melun, France (christophe.vinsonneau@ch-melun.fr).

Published Online: September 20, 2016. doi:10.1001/jama.2016.11329

Conflict of Interest Disclosures: The authors have completed and submitted the ICMJE Form for Disclosure of Potential Conflicts of Interest and none were reported.

REFERENCES

Zarbock  A, Kellum  JA, Schmidt  C,  et al.  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. JAMA. 2016;315(20):2190-2199.
PubMed   |  Link to Article
Gaudry  S, Hajage  D, Schortgen  F,  et al.  Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med. 2016;375(2):122-133.
PubMed   |  Link to Article

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Zarbock  A, Kellum  JA, Schmidt  C,  et al.  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. JAMA. 2016;315(20):2190-2199.
PubMed   |  Link to Article
Gaudry  S, Hajage  D, Schortgen  F,  et al.  Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med. 2016;375(2):122-133.
PubMed   |  Link to Article
May 24, 2016
Alexander Zarbock, MD; John A. Kellum, MD; Christoph Schmidt, MD; Hugo Van Aken, MD; Carola Wempe, PhD; Hermann Pavenstädt, MD; Andreea Boanta, MD; Joachim Gerß, PhD; Melanie Meersch, MD
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.
September 20, 2016
Alexander Zarbock, MD; John A. Kellum, MD
1Department of Anaesthesiology, Intensive Care Medicine, and Pain Medicine, University Hospital Münster, Germany
2Center for Critical Care Nephrology, University of Pittsburgh, Pittsburgh, Pennsylvania
JAMA. 2016;316(11):1214. doi:10.1001/jama.2016.11338.
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