Acute kidney injury in critical care: Experience of a conservative strategy

Progressively Earlier Initiation of Renal Replacement Therapy for Acute Kidney Injury Is Unwarranted and Potentially Harmful

“…An argument has been made by Ronco et al [17] that this study, along with other recent observational studies [21,23] supports a conclusion that, while early initiation may or may not be beneficial, avoiding or delaying it is associated with increased mortality. We do not agree that this has been clearly established given that recent studies do not consistently report either that delaying or avoiding RRT is harmful, or that earlier initiation is harmless [30][31][32][33][34][35][36] . In particular, multiple, observational studies published in the last 5 years suggest that delaying or avoiding RRT may be beneficial [31,32,34,35] .…”

“…We do not agree that this has been clearly established given that recent studies do not consistently report either that delaying or avoiding RRT is harmful, or that earlier initiation is harmless [30][31][32][33][34][35][36] . In particular, multiple, observational studies published in the last 5 years suggest that delaying or avoiding RRT may be beneficial [31,32,34,35] . In addition, as discussed in the next section, there are plausible explanations as to how further lowering the threshold for RRT initiation can lead to harm.…”

“…While consensus has been established that RRT should be initiated for 'conventional', potentially lifethreatening indications, the threshold for starting has been lowered such that many patients begin RRT preemptively. Despite this change in practice, there was insufficient evidence to support it: multiple observational studies have suggested decreased mortality with 'earlier' RRT [11,[21][22][23], but many others have suggested that there is no effect [33,36] or that a conservative strategy is superior [30,32,34,35] . In addition, 3 underpowered RCTs have been conducted and none of them have shown significantly improved outcomes with relatively earlier RRT initiation [20,37,38] .…”

Our paper 20 years later: from acute renal failure to acute kidney injury—the metamorphosis of a syndrome

“…This included a fraction of patients in whom therapy was withheld because of the terminal state of the patients (15 % of AKI patients, all of whom died), but also a group of patients in whom the treating physicians did not initiate RRT because they assumed that the patient could be better supported by conservative measures (12 % of patients). This group of subjects-which has received much interest in recent years-had a much better prognosis (61 % survival rate) [31,32]. With the current recommendations of ''early RRT'' the identification of such patients who actually will not profit from an early initiation presents an important aspect for the management of AKI in the future [32].…”

“…This group of subjects-which has received much interest in recent years-had a much better prognosis (61 % survival rate) [31,32]. With the current recommendations of ''early RRT'' the identification of such patients who actually will not profit from an early initiation presents an important aspect for the management of AKI in the future [32]. Overall mortality of the patients with AKI decreased from above 80 % at the beginning to about 50% at the end of the observation period of 15 years.…”