title: Can early initiation of continuous renal replacement therapy improve patient survival with septic acute kidney injury when enrolled in early goal-directed therapy?
abstract: The purpose of our study was to investigate the timing of continuous renal replacement therapy (CRRT) application, based on the interval between the start of early goal-directed therapy (EGDT) and CRRT initiation, to ascertain whether the timing was an independent predictor of mortality in patients with septic acute kidney injury (AKI).
  
  
  
  An observational retrospective cohort study was conducted of 60 patients (>18 years old) who had been admitted to the emergency department and received resuscitation according to the standard EGDT algorithm for severe sepsis and septic shock, and who were treated with CRRT due to septic AKI, between June 2008 and February 2013 at a tertiary hospital in Seoul, Korea. The patients were divided into 2 groups based on the median interval between the start of EGDT and the commencement of CRRT. The main outcome was 28-day all-cause mortality, and a multivariate Cox analysis for mortality was used to evaluate the independent impact of the early CRRT treatment.
  
  
  
  The mean patient age was 66.3 years, and 52 (86.7%) were male. The most common comorbid disease was diabetes mellitus (35.0%) followed by malignancy (26.7%). The median interval between the start of EGDT and commencement of CRRT was 26.4 hours. During the study period, 28-day mortality was 43.3% (26 of 60 patients). The 28-day all-cause mortality rate was significantly higher in the late CRRT group than in the early CRRT group (56.7 vs 30.0%, P= .037). Furthermore, the higher mortality risk in the late group remained significant even after adjusting for diabetes mellitus, liver failure, and Acute Physiology and Chronic Health Evaluation II scores (hazard ratio, 2.461; 95% confidence interval, 1.044-5.800; P= .026).
  
  
  
  Early initiation of CRRT may be of benefit. Given the complex nature of this intervention and the ongoing controversy regarding early vs late initiation of therapy in acute and chronic situations, it is vital to develop accurate clinical trials to find definitive answers.
authors.affiliation: Division of Nephrology, Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea.
authors.forename: Hyung Jung
authors.initials: HJ
authors.lastname: Oh
authors.affiliation: Division of Infection, Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea.
authors.forename: Min Hyung
authors.initials: MH
authors.lastname: Kim
authors.affiliation: Division of Infection, Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea.
authors.forename: Jin Young
authors.initials: JY
authors.lastname: Ahn
authors.affiliation: Division of Infection, Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea. Electronic address: smileboy9@yuhs.ac.
authors.forename: Nam Su
authors.initials: NS
authors.lastname: Ku
authors.affiliation: Division of Nephrology, Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea.
authors.forename: Jung Tak
authors.initials: JT
authors.lastname: Park
authors.affiliation: Division of Infection, Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea.
authors.forename: Sang Hoon
authors.initials: SH
authors.lastname: Han
authors.affiliation: Division of Infection, Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea.
authors.forename: Jun Yong
authors.initials: JY
authors.lastname: Choi
authors.affiliation: Division of Nephrology, Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea.
authors.forename: Seung Hyeok
authors.initials: SH
authors.lastname: Han
authors.affiliation: Division of Nephrology, Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea.
authors.forename: Tae-Hyun
authors.initials: TH
authors.lastname: Yoo
authors.affiliation: Division of Infection, Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea.
authors.forename: Young Goo
authors.initials: YG
authors.lastname: Song
authors.affiliation: Division of Nephrology, Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea.
authors.forename: Shin-Wook
authors.initials: SW
authors.lastname: Kang
authors.affiliation: Division of Infection, Department of Internal Medicine, College of Medicine, Yonsei University, Seoul, Korea.
authors.forename: June Myung
authors.initials: JM
authors.lastname: Kim
mesh_terms: D018806:APACHE; D058186:Acute Kidney Injury / Q000401:mortality / Q000628:therapy*; D000368:Aged; D015331:Cohort Studies; D003422:Critical Care / Q000592:standards*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016016:Proportional Hazards Models; D058996:Quality Improvement; D017582:Renal Replacement Therapy; D056910:Republic of Korea; D012189:Retrospective Studies; D018805:Sepsis / Q000401:mortality / Q000628:therapy*; D016019:Survival Analysis
keywords: 28-Day mortality; AKI; EGDT; Early CRRT; Sepsis