Acute Kidney Injury: IDEAL-ICU (Initiation of Dialysis Early Versus Delayed in the Intensive Care Unit )

Question 1

IDEAL-ICU Clinical Question

Answer 1

Among ICU with septic shock and AKI without urgent need for dialysis, does an initiation of renal replacement therapy (RRT) using an early-initiation strategy reduce all-cause mortality at 90 days when compared to a delayed-initiation strategy?

Question 2

IDEAL-ICU Bottom Line

Answer 2

Among ICU with septic shock and AKI without urgent need for dialysis, there was no difference in 90-day all cause mortality when comparing early-initiation vs. delayed-initiation RRT strategies. Overall use of RRT was lower in the delayed-initiation strategy group.

Question 3

IDEAL-ICU Primary outcome

Answer 3

Death from any cause at 90 days after randomization

Question 4

IDEAL-ICU inclusion criteria

Answer 4

• Age ≥18 years
• Admitted to ICU within 48 hours of development of septic shock
• Acute kidney injury, per ≥1 of the RIFLE criteria:
  
  • Oliguria, defined as UOP <0.3 mL/kg/hr for ≥24h
  • Anuria for ≥12h 3x increase in serum creatinine
  • A rapid increase of creatinine to ≥4 mg/dL (≥350 umol/L)

Question 5

IDEAL-ICU interventions

Answer 5

Randomization to a group:

1. Early initiation of RRT - Initiation of RRT within 12 hours after documentation of severe AKI
2. Delayed initiation of RRT - Monitored until they meet criteria for acute indication of dialysis
   
   • K >6.5mmol/L
   • pH <7.15
   • Refractory fluid overload with pulmonary edema
   • If no acute indication for dialysis, then initiation of RRT is implemented at 48h unless renal recovery is made (decline in creatinine and urine output >1000 mL/24h).

Question 6

IDEAL-ICU Criticisms

Answer 6

1. Inconsistency between using KDIGO or RIFLE criteria for inclusion criteria exists between AKI studies in ICU populations
2. High mortality rate (68%) among those in the delayed initiation group who required RRT in the first 48 hours after randomization. Unclear if this subgroup would have benefitted from early RRT.
3. The time window delineated by this trial is arbitrary. Clinical tools to guide timing for initiation of RRT would be useful.
4. Heterogenous population, some patients may have benefitted from early RRT

Question 7

what % of patients with septic shock develop AKI

Answer 7

40-75%