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Randomized Controlled Trial
. 2018 Mar;29(3):1011-1019.
doi: 10.1681/ASN.2017060694. Epub 2017 Dec 1.

Long-Term Clinical Outcomes after Early Initiation of RRT in Critically Ill Patients with AKI

Melanie Meersch  1 , Mira Küllmar  1 , Christoph Schmidt  1 , Joachim Gerss  2 , Toni Weinhage  3 , Andreas Margraf  1 , Thomas Ermert  1 , John A Kellum  4 , Alexander Zarbock  5
Affiliations
Randomized Controlled Trial

Long-Term Clinical Outcomes after Early Initiation of RRT in Critically Ill Patients with AKI

Melanie Meersch et al. J Am Soc Nephrol. 2018 Mar.

Abstract

Whether earlier initiation of RRT in critically ill patients with AKI can improve outcomes remains debated. We examined follow-up data from a large clinical trial to prospectively investigate the long-term outcomes associated with the timing of RRT initiation in such patients. We extended the follow-up of patients in the Early Versus Delayed Initiation of RRT in Critically Ill Patients with AKI (ELAIN) Trial from 90 days to 1 year after randomization for 230 (99.6%) patients. The primary outcome was a composite of major adverse kidney events (persistent renal dysfunction, dialysis dependence, and mortality) at 1 year. Secondary outcomes included inflammatory markers. Overall, 72 of 111 (64.9%) and 106 of 119 (89.1%) patients met the primary outcome in the early (stage 2 AKI) and delayed (stage 3 AKI) initiation groups, respectively (odds ratio [OR] with early initiation, 0.23; 95% confidence interval [95% CI], 0.11 to 0.45; P< 0.001). The early initiation group had a 1-year all-cause mortality rate (56 of 111 [50.2%]) significantly lower than that of the delayed initiation group (83 of 119 [69.8%]; absolute difference, -19.6%; 95% CI, -32.0% to -7.2%; P<0.01). After 1 year, 16 of 55 (29.1%) and 23 of 36 (63.9%) surviving patients in the early and delayed groups, respectively, failed to recover renal function (absolute difference, -34.8%; 95% CI, -54.6% to -15.0%; P=0.001). In conclusion, early initiation of RRT in these critically ill patients with AKI significantly reduced the occurrence of major adverse kidney events, reduced mortality, and enhanced renal recovery at 1 year.

Keywords: acute renal failure; hemodialysis; survival.

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Figures

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Graphical abstract
Figure 1.
Figure 1.
The flowchart of the ELAIN Trial shows 231 patients were included in the initial trial and 1 patient was lost to follow-up for the follow-up analysis. CRRT, continuous RRT; NGAL, neutrophil gelatinase–associated lipocalin.
Figure 2.
Figure 2.
The Kaplan Meier analysis shows the overall mortality in the early versus the delayed RRT initiation group. Patients with early initiation of RRT showed a significant improved survival as compared with the delayed group (HR, 0.617; 95% CI, 0.439–0.866; P=0.005).
See this image and copyright information in PMC

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