DIALYSIS: Early versus delayed initiation of renal replacement therapy for acute kidney injury (May 2020)
The optimized time of renal replacement therapy (RRT) in ptns with acute kidney injury (AKI) still uncertain, and RCT that compare earlier (No clear indication can be recognized) with delayed (indications can be obviously recognized) the initiation of RRT have concluded in conflicting results. The meta-analysis of 9 trials with almost 1900 ptns with advanced AKI found that there is no significant difference in the MR (mortality rate) that reported at 28, 60, and 90 days between those receiving an earlier RRT and those receiving delayed RRT. Moreover, at hospital discharge, there were no significant difference between the groups in the proportion of ptns with RRT dependence, in SCr among those who were NOT RRT dependent, or in ventilator or vasopressor administration. We can conclude the recommendation that support to commence RRT only upon the evolution of a clear indication.
Gaudry S, Hajage D, Benichou N, et al. Delayed versus early initiation of renal replacement therapy for severe acute kidney injury: a systematic review and individual patient data meta-analysis of randomised clinical trials. Lancet 2020; 395:1506.
The National Kidney Foundation’s Kidney Disease Outcomes Quality Initiative (KDOQI) updated its guidance for HDX (hemodialysis) vascular access. Among the provided changes, they now emphasize a ptn-centered approach with creation of an ESRD (end-stage kidney disease) Life-Plan with selection of an incident and subsequent HDX vascular access that is based on individual characteristics (for example, anatomical criteria, co-morbid diseases, age, etc...), in contrary to the previous fistula-first approach. While a functioning arteriovenous (AV) fistula is still preferred to an AV graft, the guideline recognizes that an AV fistula may not be appropriate for ALL ptns.