• Ron Wald, Brian Kirkham, Bruno R daCosta, Ehsan Ghamarian, AdhikariNeill K JNKJDepartment of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Canada., William Beaubien-Souligny, Rinaldo Bellomo, Martin P Gallagher, Stuart Goldstein, HosteEric A JEAJIntensive Care Unit, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium.Research Foundation-Flanders (FWO), Brussels, Belgium., Kathleen D Liu, Javier A Neyra, Marlies Ostermann, Paul M Palevsky, Antoine Schneider, Suvi T Vaara, and Sean M Bagshaw.
• Division of Nephrology, St. Michael's Hospital, University of Toronto, 61 Queen Street East, 9-140, Toronto, ON, M5C 2T2, Canada. ron.wald@unityhealth.to.
• Crit Care. 2022 Nov 24; 26 (1): 360360.

BackgroundAmong critically ill patients with acute kidney injury (AKI), earlier initiation of renal replacement therapy (RRT) may mitigate fluid accumulation and confer better outcomes among individuals with greater fluid overload at randomization.MethodsWe conducted a pre-planned post hoc analysis of the STandard versus Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial. We evaluated the effect of accelerated RRT initiation on cumulative fluid balance over the course of 14 days following randomization using mixed models after censoring for death and ICU discharge. We assessed the modifying effect of baseline fluid balance on the impact of RRT initiation strategy on key clinical outcomes. Patients were categorized in quartiles of baseline fluid balance, and the effect of accelerated versus standard RRT initiation on clinical outcomes was assessed in each quartile using risk ratios (95% CI) for categorical variables and mean differences (95% CI) for continuous variables.ResultsAmong 2927 patients in the modified intention-to-treat analysis, 2738 had available data on baseline fluid balance and 2716 (92.8%) had at least one day of fluid balance data following randomization. Over the subsequent 14 days, participants allocated to the accelerated strategy had a lower cumulative fluid balance compared to those in the standard strategy (4509 (- 728 to 11,698) versus 5646 (0 to 13,151) mL, p = 0.03). Accelerated RRT initiation did not confer greater 90-day survival in any of the baseline fluid balance quartiles (quartile 1: RR 1.11 (95% CI 0.92 to 1.34), quartile 2: RR 1.03 (0.87 to 1.21); quartile 3: RR 1.08 (95% CI 0.91 to 1.27) and quartile 4: RR 0.87 (95% CI 0.73 to 1.03), p value for trend 0.08).ConclusionsEarlier RRT initiation in critically ill patients with AKI conferred a modest attenuation of cumulative fluid balance. Nonetheless, among patients with greater fluid accumulation at randomization, accelerated RRT initiation did not have an impact on all-cause mortality.Trial RegistrationClinicalTrials.gov number, https://clinicaltrials.gov/ct2/show/NCT02568722 , registered October 6, 2015.© 2022. The Author(s).

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