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

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; < 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%; <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%; =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.

Acute kidney injury: Epidemiology, outcomes, complications, and therapeutic strategies

“…More recently Meersch et al. examined the long‐term outcomes from follow‐up data in the ELAIN study . Early initiation of RRT in critically ill patients with AKI significantly reduced the rate of major adverse events (persistent renal dysfunction, dialysis dependence, mortality) at 1 year compared with delayed initiation of RRT (early initiation:delayed initiation = 50.2% vs 69.8%, P < .01).…”

“…One RCT and a few observational studies have focused on the impact of the initiation of RRT for AKI on long‐term (beyond 90 days) mortality or long‐term risk of ESRD. A recent cohort study conducted at Aarhus.…”

Acute kidney injury and disease: Long‐term consequences and management

“…By the end of 12 months of follow up, in the Early Versus Delayed Initiation of RRT in Critically Ill Patients with AKI (ELAIN) trial, they evaluated the impact of timing of RRT on the long‐term outcomes in such patients. The investigators concluded that early initiation of RRT in both stage 2 and stage 3 AKI reduced persistent renal dysfunction, dialysis dependence and mortality at 1 year (OR of 0.23 with early initiation; 95% CI = 0.11–0.45; P < 0.001) . The results from the extended study of Randomized Evaluation of Normal vs Augmented levels of RRT (POST‐RENAL) cohort found no benefit in long‐term mortality and ESRD progression based on the intensity of dialysis in the acute phase .…”

“…The investigators concluded that early initiation of RRT in both stage 2 and stage 3 AKI reduced persistent renal dysfunction, dialysis dependence and mortality at 1 year (OR of 0.23 with early initiation; 95% CI = 0.11-0.45; P < 0.001). 78 The results from the extended study of Randomized Evaluation of Normal vs Augmented levels of RRT (POST-RENAL) cohort found no benefit in long-term mortality and ESRD progression based on the intensity of dialysis in the acute phase. 79 However, Bell et al, in collaboration with the Swedish Intensive Care Nephrology Group, concluded that CRRT compared with intermittent RRT had a bigger chance of renal recovery.…”

Briefly Noted

“…An extended 1 year follow‐up of 230 patients in the Early v Delayed Initiation of RRI in critically Ill Patients (ELAIN) Trial found that the early group had significantly lower rates of mortality (50% vs 70%) and failure to recover renal function (29% vs 64%) than the late group …”