Jeong Rachel, Bagshaw Sean M, Ghamarian Ehsan, Harvey Andrea, Joannidis Michael, Kirkham Brian, McAuley Danny, Ostermann Marlies, Quenot Jean-Pierre, Young Paul J, Wald Ron
Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada.
Department of Medicine, Division of Nephrology, University of Calgary, Calgary, AB, Canada.
Crit Care Med. 2025 Mar 3. doi: 10.1097/CCM.0000000000006616.
Among critically ill patients with severe acute kidney injury (AKI) who lack emergent indications for renal replacement therapy (RRT), a strategy of preemptive RRT initiation does not lead to improved outcomes. However, for patients with persistent AKI and without urgent indications for RRT, the safety of prolonged delays in RRT initiation is unclear. We sought to assess the association between progressively longer delays in RRT initiation and clinical outcomes.
A post hoc secondary analysis.
The multinational STandard vs. Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial.
Participants allocated to the standard strategy of the STARRT-AKI trial.
The exposure was time from randomization to RRT initiation, evaluated in quartiles and as a continuous variable.
The primary outcome was all-cause mortality at 90 days. Secondary outcomes were RRT dependence, RRT-free days, and hospital-free days, all at 90 days, as well length of ICU and hospital stay. Of the 1462 participants allocated to the standard strategy group, 903 (62%) received RRT. Median time (interquartile range) to RRT initiation was 12.1 hours (8.3-13.8 hr), 24.5 hours (21.8-26.5 hr), 46.8 hours (35.2-52.1 hr), and 96.1 hours (76.7-139.2 hr) in quartiles 1-4, respectively. Prolonged time to RRT initiation was associated with a lower risk of death at 90 days (quartile 4 vs. 1: adjusted odds ratio, 0.63 [95% CI, 0.42-0.94]); further analyses using cubic splines and inverse probability weighting to account for immortal time bias showed no association with the risk of death. There was no association between time to RRT initiation and RRT-free days, hospital-free days, or lengths of ICU or hospital stay. Longer delay to RRT initiation had a linear association with RRT dependence at 90 days.
Among patients with no urgent indications and who received RRT in the standard strategy of the STARRT-AKI trial, longer deferral of RRT initiation was not associated with a higher risk of mortality.
在缺乏肾脏替代治疗（RRT）紧急指征的重症急性肾损伤（AKI）患者中，抢先启动RRT的策略并不能改善预后。然而，对于持续性AKI且无RRT紧急指征的患者，延迟启动RRT较长时间的安全性尚不清楚。我们试图评估RRT启动延迟时间逐渐延长与临床结局之间的关联。
事后二次分析。
多国急性肾损伤肾脏替代治疗标准与加速启动（STARRT-AKI）试验。
分配至STARRT-AKI试验标准策略组的参与者。
暴露因素为从随机分组到RRT启动的时间，按四分位数评估并作为连续变量。
主要结局为90天时的全因死亡率。次要结局为90天时的RRT依赖、无RRT天数、无住院天数，以及重症监护病房（ICU）住院时间和总住院时间。在分配至标准策略组的1462名参与者中，903名（62%）接受了RRT。第1至4四分位数中，RRT启动的中位时间（四分位间距）分别为12.1小时（8.3 - 13.8小时）、24.5小时（21.8 - 26.5小时）、46.8小时（35.2 - 52.1小时）和96.1小时（76.7 - 139.2小时）。RRT启动时间延长与90天时较低的死亡风险相关（第4四分位数与第1四分位数相比：调整后的优势比，0.63 [95% CI，0.42 - 0.94]）；使用三次样条和逆概率加权法进行的进一步分析以校正不朽时间偏倚，结果显示与死亡风险无关联。RRT启动时间与无RRT天数、无住院天数或ICU住院时间和总住院时间均无关联。RRT启动延迟时间延长与90天时的RRT依赖呈线性关联。
在无紧急指征且接受STARRT-AKI试验标准策略RRT治疗的患者中，RRT启动延迟时间延长与较高的死亡风险无关。
