Timing of the Initiation of Kidney Dialysis

Acute kidney injury is a common complication for patients in intensive care. If acute kidney injury is not treated, abnormal levels of salts and chemicals can build up in the body, and if severe this can be fatal. The usual treatment is dialysis in which a machine removes waste products from the blood. But, determining the right time to initiate dialysis is complex, and surprisingly, after nearly 50 years of performing dialysis, the medical profession has not been in agreement as to when this first treatment should begin. Patients need immediate dialysis if they have metabolic conditions such as excessive blood levels of potassium (hyperkalaemia), acid (metabolic acidosis) or waste products like urea (uraemia). But for patients without these complications, doctors have not known what the benefits or dangers of early dialysis are.

The STARRT-AKI (Standard versus Accelerated Initiation of Renal-Replacement Therapy in Acute Kidney Injury) trial, coordinated in New Zealand by the MRINZ, shows that starting dialysis within 12 hours of acute kidney injury does not improve survival nor lead to other benefits when compared with a conservative strategy based on ‘watchful waiting’ and delayed dialysis.

Importantly, it increases the risk of long-term dependence on renal-replacement therapy.

The discovery that starting dialysis early might be unnecessary in some patients and could cause further damage to the kidneys leading to long term impairment is important; dialysis is an expensive treatment, and employing it unnecessarily is a poor use of resources. This landmark trial distinctly shows that the initiation of kidney dialysis in critically ill patients with acute kidney injury can be deferred until a clear indication for dialysis is present. This approach will reduce costs and decrease the risk of patients ending up dialysis-dependent.