TY - JOUR
T1 - Fluid balance and renal replacement therapy initiation strategy
T2 - a secondary analysis of the STARRT-AKI trial
AU - Wald, Ron
AU - Kirkham, Brian
AU - daCosta, Bruno R.
AU - Ghamarian, Ehsan
AU - Adhikari, Neill K.J.
AU - Beaubien-Souligny, William
AU - Bellomo, Rinaldo
AU - Gallagher, Martin P.
AU - Goldstein, Stuart
AU - Hoste, Eric A.J.
AU - Liu, Kathleen D.
AU - Neyra, Javier A.
AU - Ostermann, Marlies
AU - Palevsky, Paul M.
AU - Schneider, Antoine
AU - Vaara, Suvi T.
AU - Bagshaw, Sean M.
N1 - Funding Information:
Canadian Institutes of Health Research (Open Operating Grant MOP142296 and Project Grant 389635); Canadian Institutes of Health Research in partnership with Baxter (Industry-Partnered Operating Grant IPR 139081); National Health Medical Research Council of Australia (Project Grant 1127121); the Health Research Council of New Zealand (Project Grant 17/204) and the National Institutes of Health Research Health Technology Assessment Program (United Kingdom) (Reference Number: 17/42/74). In 2017, the STARRT-AKI was adopted by the National Institutes for Health Research (United Kingdom) as a portfolio study.
Funding Information:
Dr. Bagshaw is supported by a Canada Research Chair in Critical Care Outcomes and Systems Evaluation. WBS is supported by the KRESCENT program of the Kidney Foundation of Canada.
Funding Information:
Ron Wald has received speaker fees an unrestricted research funding from Baxter. MO has received speaker fees and research support from Fresenius Medical Care and Baxter and research funding from Biomerieux. WBS has received speaker fees from Baxter. AS has received speaker fees and research from Fresenius Medical Care and B Braun Avitum and research funding from B Braun Avitum.
Publisher Copyright:
© 2022, The Author(s).
PY - 2022/12
Y1 - 2022/12
N2 - Background: Among critically ill patients with acute kidney injury (AKI), earlier initiation of renal replacement therapy (RRT) may mitigate fluid accumulation and confer better outcomes among individuals with greater fluid overload at randomization. Methods: We conducted a pre-planned post hoc analysis of the STandard versus Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial. We evaluated the effect of accelerated RRT initiation on cumulative fluid balance over the course of 14 days following randomization using mixed models after censoring for death and ICU discharge. We assessed the modifying effect of baseline fluid balance on the impact of RRT initiation strategy on key clinical outcomes. Patients were categorized in quartiles of baseline fluid balance, and the effect of accelerated versus standard RRT initiation on clinical outcomes was assessed in each quartile using risk ratios (95% CI) for categorical variables and mean differences (95% CI) for continuous variables. Results: Among 2927 patients in the modified intention-to-treat analysis, 2738 had available data on baseline fluid balance and 2716 (92.8%) had at least one day of fluid balance data following randomization. Over the subsequent 14 days, participants allocated to the accelerated strategy had a lower cumulative fluid balance compared to those in the standard strategy (4509 (− 728 to 11,698) versus 5646 (0 to 13,151) mL, p = 0.03). Accelerated RRT initiation did not confer greater 90-day survival in any of the baseline fluid balance quartiles (quartile 1: RR 1.11 (95% CI 0.92 to 1.34), quartile 2: RR 1.03 (0.87 to 1.21); quartile 3: RR 1.08 (95% CI 0.91 to 1.27) and quartile 4: RR 0.87 (95% CI 0.73 to 1.03), p value for trend 0.08). Conclusions: Earlier RRT initiation in critically ill patients with AKI conferred a modest attenuation of cumulative fluid balance. Nonetheless, among patients with greater fluid accumulation at randomization, accelerated RRT initiation did not have an impact on all-cause mortality. Trial registration: ClinicalTrials.gov number, https://clinicaltrials.gov/ct2/show/NCT02568722, registered October 6, 2015.
AB - Background: Among critically ill patients with acute kidney injury (AKI), earlier initiation of renal replacement therapy (RRT) may mitigate fluid accumulation and confer better outcomes among individuals with greater fluid overload at randomization. Methods: We conducted a pre-planned post hoc analysis of the STandard versus Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial. We evaluated the effect of accelerated RRT initiation on cumulative fluid balance over the course of 14 days following randomization using mixed models after censoring for death and ICU discharge. We assessed the modifying effect of baseline fluid balance on the impact of RRT initiation strategy on key clinical outcomes. Patients were categorized in quartiles of baseline fluid balance, and the effect of accelerated versus standard RRT initiation on clinical outcomes was assessed in each quartile using risk ratios (95% CI) for categorical variables and mean differences (95% CI) for continuous variables. Results: Among 2927 patients in the modified intention-to-treat analysis, 2738 had available data on baseline fluid balance and 2716 (92.8%) had at least one day of fluid balance data following randomization. Over the subsequent 14 days, participants allocated to the accelerated strategy had a lower cumulative fluid balance compared to those in the standard strategy (4509 (− 728 to 11,698) versus 5646 (0 to 13,151) mL, p = 0.03). Accelerated RRT initiation did not confer greater 90-day survival in any of the baseline fluid balance quartiles (quartile 1: RR 1.11 (95% CI 0.92 to 1.34), quartile 2: RR 1.03 (0.87 to 1.21); quartile 3: RR 1.08 (95% CI 0.91 to 1.27) and quartile 4: RR 0.87 (95% CI 0.73 to 1.03), p value for trend 0.08). Conclusions: Earlier RRT initiation in critically ill patients with AKI conferred a modest attenuation of cumulative fluid balance. Nonetheless, among patients with greater fluid accumulation at randomization, accelerated RRT initiation did not have an impact on all-cause mortality. Trial registration: ClinicalTrials.gov number, https://clinicaltrials.gov/ct2/show/NCT02568722, registered October 6, 2015.
KW - Acute kidney injury
KW - Clinical outcomes
KW - Fluid balance
KW - Randomized controlled trial
KW - Renal replacement therapy
UR - https://www.scopus.com/pages/publications/85142520764
U2 - 10.1186/s13054-022-04229-0
DO - 10.1186/s13054-022-04229-0
M3 - Article
C2 - 36424662
AN - SCOPUS:85142520764
SN - 1364-8535
VL - 26
JO - Critical Care
JF - Critical Care
IS - 1
M1 - 360
ER -