title: Effect of Early vs Delayed Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients With Acute Kidney Injury: The ELAIN Randomized Clinical Trial.
abstract: OBJECTIVE
  Optimal timing of initiation of renal replacement therapy (RRT) for severe acute kidney injury (AKI) but without life-threatening indications is still unknown.
  
  
  OBJECTIVE
  To determine whether early initiation of RRT in patients who are critically ill with AKI reduces 90-day all-cause mortality.
  
  
  METHODS
  Single-center randomized clinical trial of 231 critically ill patients with AKI Kidney Disease: Improving Global Outcomes (KDIGO) stage 2 (≥2 times baseline or urinary output <0.5 mL/kg/h for ≥12 hours) and plasma neutrophil gelatinase-associated lipocalin level higher than 150 ng/mL enrolled between August 2013 and June 2015 from a university hospital in Germany.
  
  
  METHODS
  Early (within 8 hours of diagnosis of KDIGO stage 2; n = 112) or delayed (within 12 hours of stage 3 AKI or no initiation; n = 119) initiation of RRT.
  
  
  METHODS
  The primary end point was mortality at 90 days after randomization. Secondary end points included 28- and 60-day mortality, clinical evidence of organ dysfunction, recovery of renal function, requirement of RRT after day 90, duration of renal support, and intensive care unit (ICU) and hospital length of stay.
  
  
  RESULTS
  Among 231 patients (mean age, 67 years; men, 146 [63.2%]), all patients in the early group (n = 112) and 108 of 119 patients (90.8%) in the delayed group received RRT. All patients completed follow-up at 90 days. Median time (Q1, Q3) from meeting full eligibility criteria to RRT initiation was significantly shorter in the early group (6.0 hours [Q1, Q3: 4.0, 7.0]) than in the delayed group (25.5 h [Q1, Q3: 18.8, 40.3]; difference, -21.0 [95% CI, -24.0 to -18.0]; P < .001). Early initiation of RRT significantly reduced 90-day mortality (44 of 112 patients [39.3%]) compared with delayed initiation of RRT (65 of 119 patients [54.7%]; hazard ratio [HR], 0.66 [95% CI, 0.45 to 0.97]; difference, -15.4% [95% CI, -28.1% to -2.6%]; P = .03). More patients in the early group recovered renal function by day 90 (60 of 112 patients [53.6%] in the early group vs 46 of 119 patients [38.7%] in the delayed group; odds ratio [OR], 0.55 [95% CI, 0.32 to 0. 93]; difference, 14.9% [95% CI, 2.2% to 27.6%]; P = .02). Duration of RRT and length of hospital stay were significantly shorter in the early group than in the delayed group (RRT: 9 days [Q1, Q3: 4, 44] in the early group vs 25 days [Q1, Q3: 7, >90] in the delayed group; P = .04; HR, 0.69 [95% CI, 0.48 to 1.00]; difference, -18 days [95% CI, -41 to 4]; hospital stay: 51 days [Q1, Q3: 31, 74] in the early group vs 82 days [Q1, Q3: 67, >90] in the delayed group; P < .001; HR, 0.34 [95% CI, 0.22 to 0.52]; difference, -37 days [95% CI, -∞ to -19.5]), but there was no significant effect on requirement of RRT after day 90, organ dysfunction, and length of ICU stay.
  
  
  CONCLUSIONS
  Among critically ill patients with AKI, early RRT compared with delayed initiation of RRT reduced mortality over the first 90 days. Further multicenter trials of this intervention are warranted.
  
  
  BACKGROUND
  German Clinical Trial Registry Identifier: DRKS00004367.
authors.affiliation: Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Germany.
authors.forename: Alexander
authors.initials: A
authors.lastname: Zarbock
authors.affiliation: Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh, Pennsylvania.
authors.forename: John A
authors.initials: JA
authors.lastname: Kellum
authors.affiliation: Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Germany.
authors.forename: Christoph
authors.initials: C
authors.lastname: Schmidt
authors.affiliation: Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Germany.
authors.forename: Hugo
authors.initials: H
authors.lastname: Van Aken
authors.affiliation: Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Germany.
authors.forename: Carola
authors.initials: C
authors.lastname: Wempe
authors.affiliation: Department of Internal Medicine D, University Hospital Münster, Germany.
authors.forename: Hermann
authors.initials: H
authors.lastname: Pavenstädt
authors.affiliation: Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Germany.
authors.forename: Andreea
authors.initials: A
authors.lastname: Boanta
authors.affiliation: Institute of Biostatistics and Clinical Research, University of Münster, Münster, Germany.
authors.forename: Joachim
authors.initials: J
authors.lastname: Gerß
authors.affiliation: Department of Anaesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Germany.
authors.forename: Melanie
authors.initials: M
authors.lastname: Meersch
mesh_terms: D058186:Acute Kidney Injury / Q000097:blood / Q000628:therapy*; D000209:Acute-Phase Proteins; D000368:Aged; D000369:Aged, 80 and over; D016638:Critical Illness; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D000071068:Lipocalin-2; D054834:Lipocalins / Q000097:blood; D008297:Male; D008875:Middle Aged; D011518:Proto-Oncogene Proteins / Q000097:blood; D017582:Renal Replacement Therapy; D016019:Survival Analysis; D013997:Time Factors; D016896:Treatment Outcome
chemical_list: D000209:Acute-Phase Proteins; C489506:LCN2 protein, human; D000071068:Lipocalin-2; D054834:Lipocalins; D011518:Proto-Oncogene Proteins