Department of Critical Care Medicine, Cumming School of Medicine, University of Calgary, Calgary.
Division of Nephrology, St. Michael's Hospital and the University of Toronto and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto.
Curr Opin Crit Care. 2021 Dec 1;27(6):573-581. doi: 10.1097/MCC.0000000000000891.
The optimal timing of renal-replacement therapy (RRT) initiation for the management of acute kidney injury (AKI) in the intensive care unit (ICU) is frequently controversial. An earlier-strategy has biological rationale, even in the absence of urgent indications; however, a delayed-strategy may prevent selected patients from receiving RRT and avoid complications related to RRT.
Previous studies assessing the optimal timing of RRT initiation found conflicting results, contributing to variation in clinical practice. The recent multinational trial, standard vs. accelerated initiation of renal replacement therapy in acute kidney injury (STARRT-AKI) found no survival benefit and a higher risk of RRT dependence with an accelerated compared to a standard RRT initiation strategy in critically ill patients with severe AKI. Nearly 40% of patients allocated to the standard-strategy group did not receive RRT. The Artificial Kidney Initiation in Kidney Injury-2 (AKIKI-2) trial further assessed delayed compared to more-delayed strategies for RRT initiation. The more-delayed strategy did not confer an increase in RRT-free days and was associated with a higher risk of death.
Early preemptive initiation of RRT in critically ill patients with AKI does not confer clear clinical benefits. However, protracted delays in RRT initiation may be harmful.
在重症监护病房（ICU）中，急性肾损伤（AKI）管理中肾脏替代治疗（RRT）开始的最佳时机经常存在争议。即使没有紧急指征，早期策略也有生物学依据；然而，延迟策略可能会使部分患者无法接受 RRT，并避免与 RRT 相关的并发症。
以前评估 RRT 开始最佳时机的研究得出了相互矛盾的结果，导致临床实践存在差异。最近的一项多国试验，即急性肾损伤中标准与加速肾脏替代治疗的启动（STARRT-AKI）研究发现，与标准 RRT 启动策略相比，在重症 AKI 患者中，加速 RRT 启动策略并没有带来生存获益，反而增加了 RRT 依赖的风险。近 40%的标准策略组患者未接受 RRT。人工肾在肾损伤中的启动 2 期（AKIKI-2）试验进一步评估了与更延迟策略相比，延迟与更延迟策略的 RRT 启动。更延迟的策略并没有增加无 RRT 天数，反而增加了死亡风险。
在 AKI 的重症患者中早期抢先开始 RRT 并没有带来明显的临床获益。然而，延迟开始 RRT 可能会造成危害。
