The Pt is Sick - rather Critically ill & Septic (he has been transferred to ICU- isn't that obvious..).You intubate him due to impending respiratory failure.Vasopressor's are to be started. Central Line placement preparations are ongoing- Nephrologist rounding on a next room Pt says- why don't you place a Dialysis Catheter & save yourself a second line.You look at the Intensivist - a sly nod says - 'Ignore the Request'.





After stabilizing the Pt (a relative term - since he is still critically ill), you notice the Kidney Function is indeed poor, creatinine is raised (Maybe you should have listened to the Nephrologist).Like a diligent final year Resident you order a Foley (ICU manager is not happy - she is trying to control CAUTI - a new quality control measure), FeNA calculations studies are sent, Fluid resuscitation completed.





As you bring up the Nephrologist's comment - terms like RIFLE are thrown around (the sign on Hospital door says no Firearms - Rifle ?).The Fellow chimes in - it's KDIGO Criteria now - really - 2 more Terms / Acronyms, to learn / remember.





Everything is a learning experience or Teaching opportunity it seems.Next day the Fellow is to discuss the Merits of Early vs Late Dialysis in Severe Sepsis +/- Shock Pt's.





There are some absolute truth's (He starts) - like Dialysis indications - Severe Hyperkalemia, Refractory Acidosis, Refractory Volume overload - leading to Hypoxia & Uremia induced Complications (you add these to the truths you know - Taxes / Death).Rest all is Grey - hmm (even severe, refractory, complications - sound Grey..). Seems like Acute Kidney Injury increases mortality, ICU length of stay & adds some Billions to cost.That's okay, but where are the fancy named Trials....





ELAIN Trial published in JAMA May24th 2016 (315);pp:2190-99 ,

was a single center randomized study in Critically Ill Pt's. Early Dialysis in KDIGO Stage 2 Pt's (within 8 hrs) was compared to Delayed Dialysis (within 12 hours of reaching KDIGO Stage 3. The trial randomized 231 Pt's (112 - Early vs 119 - Delayed). A significant improvement in mortality was seen in Early Dialyzed Pt's (39.3% vs 54.7%; p<0.01). Even secondary outcomes were remarkably better in Early Dialyzed Pt's - shorter ICU Stay, shorter MV need.





Seems - Case Closed - But -'There's always a But' - Remarkably - HD in Early group was started 6 hrs after randomization while Delayed Grp underwent HD 25.5 hrs after randomization. A < 19 hrs delay - and such a significant difference! 100% of early arm Pt's were dialyzed, while > 90% in delayed arm required HD -'Seems like every Critically ill pt should be Dialyzed'.





This led to 2 other multi center randomized trials:





AKIKI Trial in NEJM July 14th 2016; was carried out across 31 ICU'S. 620 pt's with Stage 3 KDIGO + vasopressor or Mechanical Ventilator need were randomized. 311 to Early Arm (HD started immediately after randomization) & 308 to Delayed Arm (they were dialyzed if they met the absolute truths of need for HD.

- No difference in primary endpoint of mortality at 60 days. (48.5% Early vs 49.7% in Delayed Arm).

- 49% pt's in delayed arm did not need dialysis.

- N o difference in secondary outcomes of Ventilator / vasopressor free days days & ICU length of stay.





IDEAL ICU trial in NEJM Oct 11th 2018 , used the RIFLE Criteria - 'Failure stage in Septic Shock' - to randomize 488 Pt's; Early Dialysis (239 pt) vs Late(after 48 hrs) Dialysis (242 Pt's).The trial found no difference in 90 day mortality (58% Early vs 54% Delayed.No difference in secondary outcomes of ICU/Hospital LOS; Vaopressor; MV free days was seen.

29% Pt's in delayed arm did not need Dialysis.





So What now: the 2 multi center randomized trials reaffirm that we can delay HD in critically ill Pt's (mortality similar in both approaches; also 29%+ Pt's may spontaneously recover function & avoid HD). However these Critically ill Pt's need to be closely monitored with labs - maybe twice daily to see if criteria for HD are being met (Pt's requiring emergent dialysis had a higher mortality but they were also the sickest - so mortality could not be attributed to delay).















