Progressively Earlier Initiation of Renal Replacement Therapy for Acute Kidney Injury Is Unwarranted and Potentially Harmful

Background: The optimal timing of renal replacement therapy (RRT) initiation for acute kidney injury (AKI) is unknown. There is debate as to whether starting RRT earlier for AKI is superior to starting it only after 'conventional', life-threatening indications are present.

Summary: In recent years, there has been an ongoing trend in clinical practice to initiate RRT for AKI long before indications appear. Observational studies show many patients now begin RRT for AKI in the absence of 'conventional' indications. While this shift may have been prompted by observational studies suggesting improved outcomes with earlier RRT, there was not sufficient justification for a change in clinical practice: many recent, observational studies suggest that early RRT may not beneficial or may be even harmful. Moreover, none of 3 underpowered RCTs reported to date found 'early' RRT initiation beneficial. Lowering the threshold for RRT initiation inevitably leads to more patients receiving unnecessary treatment and this is a matter of concern, considering the fact that complications are potentially fatal and RRT is very costly. While we await definitive studies, calls to shift clinical practice back toward the initiation of RRT for 'conventional', life-threatening indications only, should be heeded.

Key messages: 'Earlier' initiation of RRT for AKI is already occurring in clinical practice but is not justified on the basis of the studies to date. Lowering the threshold for initiation leads to more patients receiving unnecessary RRT. RRT has potentially fatal complications and is expensive. While we await definitive trials, RRT should be started only after 'conventional', life-threatening indications occur and not earlier.