Early renal replacement therapy (RRT) is no more beneficial than delayed RRT in the management of severe acute kidney injury (AKI) after septic shock without hyperkalemia, metabolic acidosis, or fluid overload. Investigators reported the new findings online ahead of print in the New England Journal of Medicine.

For the IDEAL-ICU trial (Initiation of Dialysis Early Versus Delayed in the Intensive Care Unit), Jean‑Pierre Quenot, MD, PhD, of the Hospital Center University François Mitterand, and colleagues randomly assigned 477 patients to RRT within 12 hours or after 48 hours of AKI onset. Ultimately, 38% of patients assigned to delayed RRT did not receive it. In addition, emergency RRT was required by 17% of delayed RRT patients. Results showed that 58% of the early RRT group and 54% of the delayed RRT group died within 90 days, a nonsignificant difference between the groups.

Fluid removal via RRT may not be feasible in patients with hemodynamic instability, according to the researchers.

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“Although our trial did not show any benefit to expediting the initiation of renal-replacement therapy in the absence of emergency criteria, our results cannot be interpreted as encouraging indefinite deferral of renal-replacement therapy,” Dr Quenot and the team cautioned. “Rather, our data indicate that the risk of death is not increased if renal-replacement therapy is postponed for at least 48 hours, as long as care is taken to identify patients in whom criteria for emergency renal-replacement therapy are likely to be met.”

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Barbar SD, Clere‑Jehl R, Bourredjem A, et al. Timing of renal-replacement therapy in patients with acute kidney injury and sepsis. N Engl J Med. 2018;379:1431-1442. DOI: 10.1056/NEJMoa1803213 (Published online October 10, 2018)