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Kidney Week

Abstract: FR-PO004

Dialysis Initiation in AKI: An Evaluation of the Wait and See Approach

Session Information

Category: Acute Kidney Injury

  • 101 AKI: Epidemiology, Risk Factors, and Prevention

Authors

  • Macedo, Etienne, University of California San Diego, La Jolla, California, United States
  • Ostermann, Marlies, Guy's & St Thomas' Hospital, London, United Kingdom
  • Tolwani, Ashita J., University of Alabama, Birmingham, Alabama, United States
  • Zarbock, Alexander, University Hospital Münster, Münster, Germany
  • Bouchard, Josee, Hopital du Sacre-Coeur de Montreal, Montreal, Quebec, Canada
  • Mehta, Ravindra L., University of California San Diego Medical Center, La Jolla, California, United States
Background

The optimal timing of RRT initiation in critically ill patients has been an area of intense investigation. Recent trials have suggested that dialysis may be avoided in patients with severe AKI by waiting to initiate therapy unless there are life-threatening complications requiring emergent intervention. We evaluated the outcomes of this “wait and see approach” (WS) in comparison to elective intervention based on the severity of AKI and non-emergent indications. We hypothesized that the WS approach would be associated with higher mortality and resource utilization.

Methods

We conducted a retrospective multinational cohort study of critically ill adult patients admitted to four centers in Germany, UK and USA between Jan2014 and Dec2017. We excluded patients with ESRD, kidney transplant and those who stayed <72hrs. in the ICU. Need for dialysis was classified as emergent, defined as AKI Stg2 or higher, in the presence of any one of the criteria 1) arterial blood gas pH<7.15, 2) K>= 6.5 Meq/L, 3) BUN>112 mg/dl or 4) PO2/FIO2<=150 with cumulative fluid balance from admission >= 15%. Urgent initiation was considered if patients had AKI Stg3 and none of the emergency criteria, and elective for the rest of the indications. The primary outcome was ICU and hospital mortality.

Results

Of 20,560 eligible patients, 9712 (47.2) developed AKI (2,156;10.5) received dialysis (D); of whom 438(20) at dialysis initiation were at Stg1, 124(5) Stg2, 380(17) Stg3 and 953(44) no AKI. They were categorized as elective (2156;76), urgent (252;11) and emergent (252;11). Among 18404 non-dialyzed (ND) patients, 253(1.4%) met the urgent and 127(0.7%) the emergent criteria. Dialyzed patients had higher SOFA scores, vasopressor need, mechanical ventilation, and cumulative fluid balance. Hospital mortality in D patients was almost 2 fold higher as compared to urgent and elective groups, and in the ND patients hospital mortality was > 2 fold higher when urgent and 4.5 fold higher when emergent criteria were present. D and ND patients had similar mortality in emergent category.

Conclusion

Reaching emergency criteria was associated with higher ICU and hospital mortality in dialyzed and non-dialyzed patients. Further studies are needed to identify appropriate criteria for initiating dialysis in ICU patients.

Funding

  • NIDDK Support