The ELAIN Trial shows advantages of early RRT

In critically ill patients with stage 2 AKI, early RRT leads to lower mortality compared with delayed RRT, reports a trial in The Journal of the American Medical Association

The randomized ELAIN Trial included 231 patients with KDIGO stage 2 AKI and plasma neutrophil gelatinase-associated lipocalin levels greater than 150 ng/mL. All patients were treated at a single German center. One group received early RRT that was initiated within 8 hours of diagnosis of stage 2 AKI. The other group received delayed AKI that was initiated within 3 hours of developing stage 3 AKI.

Nearly two-thirds of patients were men; the mean age was 67 years old. All patients in the early group received RRT along with 90.8 percent in the delayed group. Median times for eligibility for RRT initiation were 6.0 and 25.5 hours, respectively.

Ninety-day mortality was 39.3 percent with early RRT versus 54.7 percent with delayed RRT (hazard ratio of 0.66) (4). Patients assigned to early RRT had a higher rate of recovery of renal function by 90 days (53.6 versus 38.7 days), shorter duration of RRT (9 versus 25 days), and shorter hospital stay (51 versus 82 days). There were no significant differences in RRT after 90 days, organ dysfunction, or length of ICU stay.

The optimal timing of RRT for severe AKI without life-threatening indications remains unclear, although evidence suggests benefits of early RRT. The ELAIN Trial results show reduced 90-day mortality of an early RRT strategy for stage 2 AKI. The investigators conclude, “[o]ur study provides important feasibility data for an AKI stage-based biomarker-guided interventional trial in AKI” [Zarbock A, et al. Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury: The ELAIN Randomized Clinical Trial. JAMA 2016; 315:2190–2199].