Regional Practice Variation and Outcomes in the Standard Versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) Trial: A Post Hoc Secondary Analysis

Suvi T. Vaara, MD, PhD; Ary Serpa Neto, MD, PhD; Rinaldo Bellomo, MD, PhD; Neill K. J. Adhikari, MDCM, MSc; Didier Dreyfuss, MD, PhD; Martin Gallagher, MD, PhD; Stephane Gaudry, MD, PhD; Eric Hoste, MD, PhD; Michael Joannidis, MD; Ville Pettilä, MD, PhD; Amanda Y. Wang, MD, PhD; Kianoush Kashani, MD, PhD; Ron Wald, MDCM, MPH; Sean M. Bagshaw, MD, MSc; Marlies Ostermann, MD, PhD; Sean M Bagshaw

doi:10.1097/CCE.0000000000001053

Critical Care Explorations (Feb 2024)

Regional Practice Variation and Outcomes in the Standard Versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) Trial: A Post Hoc Secondary Analysis

Suvi T. Vaara, MD, PhD,
Ary Serpa Neto, MD, PhD,
Rinaldo Bellomo, MD, PhD,
Neill K. J. Adhikari, MDCM, MSc,
Didier Dreyfuss, MD, PhD,
Martin Gallagher, MD, PhD,
Stephane Gaudry, MD, PhD,
Eric Hoste, MD, PhD,
Michael Joannidis, MD,
Ville Pettilä, MD, PhD,
Amanda Y. Wang, MD, PhD,
Kianoush Kashani, MD, PhD,
Ron Wald, MDCM, MPH,
Sean M. Bagshaw, MD, MSc,
Marlies Ostermann, MD, PhD,
Sean M Bagshaw

Affiliations

Suvi T. Vaara, MD, PhD: 1 Department of Perioperative and Intensive Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
Ary Serpa Neto, MD, PhD: 2 Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
Rinaldo Bellomo, MD, PhD: 2 Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
Neill K. J. Adhikari, MDCM, MSc: 8 Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
Didier Dreyfuss, MD, PhD: 11 French National Institute of Health and Medical Research (INSERM), UMR_S1155, CORAKID, Hôpital Tenon, Sorbonne Université, Paris, France.
Martin Gallagher, MD, PhD: 13 South Western Sydney Clinical Campus, Faculty of Medicine & Health, University of New South Wales, New South Wales, NSW, Australia.
Stephane Gaudry, MD, PhD: 11 French National Institute of Health and Medical Research (INSERM), UMR_S1155, CORAKID, Hôpital Tenon, Sorbonne Université, Paris, France.
Eric Hoste, MD, PhD: 16 Intensive Care Unit, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium.
Michael Joannidis, MD: 17 Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria.
Ville Pettilä, MD, PhD: 1 Department of Perioperative and Intensive Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
Amanda Y. Wang, MD, PhD: 13 South Western Sydney Clinical Campus, Faculty of Medicine & Health, University of New South Wales, New South Wales, NSW, Australia.
Kianoush Kashani, MD, PhD: 19 Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN.
Ron Wald, MDCM, MPH: 20 Medicine Program and Li Ka Shing Knowledge Institute, St. Michael’s Hospital, Unity Health Toronto, Toronto, ON, Canada.
Sean M. Bagshaw, MD, MSc: 22 Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada.
Marlies Ostermann, MD, PhD: 23 Department of Critical Care Medicine, King’s College London, Guy’s & St Thomas’ Hospital, London, United Kingdom.
Sean M Bagshaw

DOI: https://doi.org/10.1097/CCE.0000000000001053
Journal volume & issue: Vol. 6, no. 2
p. e1053

Abstract

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OBJECTIVES:. Among patients with severe acute kidney injury (AKI) admitted to the ICU in high-income countries, regional practice variations for fluid balance (FB) management, timing, and choice of renal replacement therapy (RRT) modality may be significant. DESIGN:. Secondary post hoc analysis of the STandard vs. Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial (ClinicalTrials.gov number NCT02568722). SETTING:. One hundred-fifty-three ICUs in 13 countries. PATIENTS:. Altogether 2693 critically ill patients with AKI, of whom 994 were North American, 1143 European, and 556 from Australia and New Zealand (ANZ). INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. Total mean FB to a maximum of 14 days was +7199 mL in North America, +5641 mL in Europe, and +2211 mL in ANZ (p < 0.001). The median time to RRT initiation among patients allocated to the standard strategy was longest in Europe compared with North America and ANZ (p < 0.001; p < 0.001). Continuous RRT was the initial RRT modality in 60.8% of patients in North America and 56.8% of patients in Europe, compared with 96.4% of patients in ANZ (p < 0.001). After adjustment for predefined baseline characteristics, compared with North American and European patients, those in ANZ were more likely to survive to ICU (p < 0.001) and hospital discharge (p < 0.001) and to 90 days (for ANZ vs. Europe: risk difference [RD], –11.3%; 95% CI, –17.7% to –4.8%; p < 0.001 and for ANZ vs. North America: RD, –10.3%; 95% CI, –17.5% to –3.1%; p = 0.007). CONCLUSIONS:. Among STARRT-AKI trial centers, significant regional practice variation exists regarding FB, timing of initiation of RRT, and initial use of continuous RRT. After adjustment, such practice variation was associated with lower ICU and hospital stay and 90-day mortality among ANZ patients compared with other regions.

Published in Critical Care Explorations

ISSN: 2639-8028 (Online)
Publisher: Wolters Kluwer
Country of publisher: United States
LCC subjects: Medicine: Internal medicine: Medical emergencies. Critical care. Intensive care. First aid
Website: https://journals.lww.com/ccejournal/pages/default.aspx

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