STandard versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury trial) – STARRT-AKI

Fernando G. Zampieri FG, da Costa BR, Vaara ST et al.

Critical Care (2022) 26: 255. https://doi.org/10.1186/s13054-022-04120-y

Background

• Acute Kidney Injury (AKI) is common in ICU
• The rationale for early dialysis include:
  • achieving optimal fluid balance via ultrafiltration
  • removal of toxic solutes that may mitigate the inflammatory milieu
  • correcting metabolic acidosis that may contribute to haemodynamic instability
  • The rationale for delaying dialysis include:
  • less procedural related risk to the patient
  • avoidance in some situations of an unnecessary intervention if the patient’s renal function improves spontaneously
  • resource rationing and avoidance of iatrogenic hypovolaemia from excessive filtration

Design & Setting

• RCT – participants randomized 1:1 to accelerated vs standard RRT
• Sample size was calculated at 2866 patients and increased to 3000 to account for attrition, eg loss to follow-up

Accelerated	Standard
Commence RRT ASAP – within 12 hours of inclusion 96.8% underwent RRT Median initiation 6.1 hours	Delayed RRT unless absolute indication or 72hours from randomization (or not at all) 61.8% underwent RRT Median initiation 31.1 hours

• Of note for the standard arm, there was no obligation to commence RRT in the standard group arm even if the criteria were met, eg if K is 6.3mmol/L, the clinician could manage it with medical therapy. Conversely, RRT could be commenced at any time deemed suitable based on the judgement of the attending clinician
• Management common to both groups
• RRT would continue until one of the following was encountered
  • Death
  • Withdrawal of life-support
  • Kidney Function Recovered

Outcomes:

• Primary outcome: 90 Day Mortality (Accelerated vs Standard)
  • NO SIGNIFICANT DIFFERENCE 
  • Relatively equal number deaths in each group
• Secondary outcome: (Accelerated vs Standard) included:
  • Significant difference in:
    • Dependence on RRT at Day 90 after randomisation (10.4% vs 6%)
    • Patients in the accelerated group had a shorter ICU stay than the standard group (9 days vs 10 days)
    • Adverse events were more common in the accelerated arm (23% v 16.5%), particularly hypotension and hypophosphataemia
    • Readmission in 90 days higher in accelerated group (20.9% v 17%)

Conclusions:

• In ICU patient with AKI, an accelerated strategy for the initiation of renal-replacement therapy did not result in a lower mortality at 90 days than a standard strategy
• There appears to be no benefit in starting renal replacement in an accelerated fashion
• In addition, early dialysis appears to increase the risk of dependence on long term renal replacement therapy raising the possibility these patients are of risk of  dialysis induced kidney injury
• Mirrors what is seen in other multicentre trials

Discussion from Journal Club Meeting:

Interesting trial – will change practice for some clinicians in the future, would be more likely to hold off RRT for as long as possible

Good to see evidence base for not starting RRT early

Will help with referrals to ICU – have clear parameters for when it would be beneficial vs detrimental to patient

Summary by Dr A Dooley. Journal Club Meeting 15 December 2022.