Fluid balance and renal replacement therapy initiation strategy: a secondary analysis of the STARRT-AKI trial
Ron Wald,
Brian Kirkham,
Bruno R. daCosta,
Ehsan Ghamarian,
Neill K. J. Adhikari,
William Beaubien-Souligny,
Rinaldo Bellomo,
Martin P. Gallagher,
Stuart Goldstein,
Eric A. J. Hoste,
Kathleen D. Liu,
Javier A. Neyra,
Marlies Ostermann,
Paul M. Palevsky,
Antoine Schneider,
Suvi T. Vaara,
Sean M. Bagshaw
Affiliations
Ron Wald
Division of Nephrology, St. Michael’s Hospital, University of Toronto
Brian Kirkham
Applied Health Research Centre, St. Michael’s Hospital
Bruno R. daCosta
Li Ka Shing Knowledge Institute of St. Michael’s Hospital
Ehsan Ghamarian
Applied Health Research Centre, St. Michael’s Hospital
Neill K. J. Adhikari
Department of Critical Care Medicine, Sunnybrook Health Sciences Centre and Interdepartmental Division of Critical Care Medicine, University of Toronto
William Beaubien-Souligny
Division of Nephrology, Centre Hospitalier de l’Université de Montréal
Rinaldo Bellomo
Department of Critical Care, School of Medicine, The University of Melbourne
Martin P. Gallagher
The George Institute for Global Health, UNSW
Stuart Goldstein
Division of Nephrology, Cincinnati Children’s Hospital
Eric A. J. Hoste
Intensive Care Unit, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University
Kathleen D. Liu
Departments of Medicine and Anesthesia, University of California
Javier A. Neyra
Division of Nephrology, University of Alabama Birmingham
Marlies Ostermann
Department of Critical Care, King’s College London, Guy’s & St Thomas’ Hospital
Paul M. Palevsky
VA Pittsburgh Healthcare System and University of Pittsburgh
Antoine Schneider
Adult Intensive Care Unit, Centre Hospitalier Universitaire Vaudois (CHUV)
Suvi T. Vaara
Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital
Sean M. Bagshaw
Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services
Abstract Background Among 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. Methods We 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. Results Among 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). Conclusions Earlier 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 registration: ClinicalTrials.gov number, https://clinicaltrials.gov/ct2/show/NCT02568722 , registered October 6, 2015.
