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EARLY RRT

No benefit from early renal replacement renal replacement therapy gutherapy initiation in critically ill patients with acute kidney injury (July 2020)

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No benefit from early renal replacement therapy initiation in critically ill patients with acute kidney injury (July 2020)


In critically ill ptns with severe acute kidney injury (AKI), the decision regarding when to initiate renal replacement therapy (RRT) still uncertain; some suggest an “early intervention” strategy (initiation as soon as severe AKI is diagnosed) while others advocate a “delayed strategy” (waiting until the ptn develops a clear indication for DX). In the Standard vs Accelerated Initiation of Renal-Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial, > 3000 critically ill cases with severe AKI and no urgent indication for RRT were randomly assigned to an early or delayed strategy. There was no difference in MR at 90 days; however, ptns assigned to the early strategy were:

1)    More likely to remain RRT-dependent,

2)    Require re-hospitalization, and

3)    More vulnerable for adverse events.

In ptns with severe AKI, we recommend against early initiation of RRT, since this approach results in increased health care utilization but does not improve, and even worsen, patients’ outcomes.  

STARRT-AKI Investigators, Canadian Critical Care Trials Group, Australian and New Zealand Intensive Care Society Clinical Trials Group, et al. Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury. N Engl J Med 2020; 383:240.

 

No benefit of urate-lowering therapy on progression of chronic kidney disease (June 2020).

Many observational studies hv reported that higher serum uric acid levels are complicated with a higher risk for newly developed ch kidney disease (CKD) as well as progression of pre-existing CKD. However, 2 large, high-quality studies now support the lack of a causal relationship and indicate that urate-lowering therapy is NOT an effective strategy to prevent CKD or slow its progression:

v  In a trial of over 500 adult patients with type 1 DM and early/moderate diabetic kidney disease, allopurinol therapy had no effect on the change in the estimated glomerular filtration rate (GFR) at 3 ys as compared to placebo; instead, allopurinol increased urine albumin excretion and non-significantly increased the rate of fatal or non-fatal CVS events.

v  In another trial of more than 350 adults with more advanced CKD, the rate of decline of estimated GFR at 2 ys was the same with allopurinol and placebo; the composite outcome of a 40 % decline in estimated GFR, end-stage renal disease, or death occurred more frequently in the allopurinol group (35 vs 28 %), but this was not statistically significant.

Doria A, Galecki AT, Spino C, et al. Serum Urate Lowering with Allopurinol and Kidney Function in Type 1 Diabetes. N Engl J Med 2020; 382:2493.

Badve SV, Pascoe EM, Tiku A, et al. Effects of Allopurinol on the Progression of Chronic Kidney Disease. N Engl J Med 2020; 382:2504.


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