Early start renal replacement therapy for acute kidney injury—Universal panacea or another case of over medicalization?

Abstract

Despite advances in medical practice and renal replacement therapy, the mortality of patients who develop acute kidney injury remains high. In the field of cardiology, the management of myocardial infarction has evolved from one of conservative bed rest to primary coronary intervention. As renal replacement therapy is now generally available, the question arises whether earlier intervention could lead to improved patient outcomes. The evidence to date is primarily centered on retrospective observational reports, with the majority reporting increased patient survival for earlier intervention. However, these reports are typically based on small numbers of patients and differ in the etiology of acute kidney injury, patient comorbidity, and definitions of what constitutes "early" start. To date, there is less than a handful of prospective randomized studies published in the modern era. Again these are small studies, with differing patient populations, and definitions of "early" start, but generally do not show any significant advantage for an "early" start approach. As such until adequately powered prospective trial data become available, the decision to initiate renal replacement therapy should be made by the traditional review of patient history, repeated clinical assessments, and trends in biochemical data.

Haste makes waste—Should current guideline recommendations for initiation of renal replacement therapy for acute kidney injury be changed?

“…There is broad consensus among guidance bodies that RRT should not be deferred in what are called “life‐threatening conditions” . Most guidelines explicitly state that clinicians should consider the broader clinical context, the presence of conditions that can be modified by RRT, and trends of laboratory tests rather than single thresholds when making the decision to start . However, there seems to be no consensus on what exactly is meant by “life‐threatening conditions,” and what the thresholds of laboratory parameters should be.…”

“…[6][7][8][9][10] Most guidelines explicitly state that clinicians should consider the broader clinical context, the presence of conditions that can be modified by RRT, and trends of laboratory tests rather than single thresholds when making the decision to start. 11 However, there seems to be no consensus on what exactly is meant by "life-threatening conditions," and what the thresholds of laboratory parameters should be. Table 1 lists some of these parameters and their suggested thresholds.…”

Cell cycle arrest biomarkers for the early prediction of acute kidney injury - full of promise, but not a must–have for yet

“…Finally, it may be attractive to know which patient will need RRT, but earlier knowledge is unlikely to change clinical practice. There is no evidence that initiation of RRT earlier than by current criteria is beneficial (30).…”