Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit
New England Journal of Medicine, 2016 · Multicenter (French), randomized controlled trial.
Clinical question
In critically ill adults with severe (KDIGO stage 3) AKI, does starting RRT immediately, rather than waiting for a strict clinical indication, improve survival?
What the trial found
Starting RRT immediately at KDIGO stage 3, rather than waiting for a strict clinical indication, did not improve 60-day survival. A substantial proportion of patients managed with watchful waiting never required RRT at all.
Current guideline position
Consistent with AKIKI, IDEAL-ICU, and STARRT-AKI (the larger, more recent trials), current practice generally favors initiating RRT based on a clinical indication rather than a fixed AKI stage or biomarker threshold alone; the KDIGO 2012 guideline predates these trials, and the KDIGO 2026 draft (not yet finalized) is expected to update RRT timing guidance based on this evidence.
Clinical interpretation
AKIKI supports a watchful-waiting approach to RRT timing in AKI without an emergent indication — closely monitoring the patient and starting RRT only if a defined indication develops, rather than initiating it pre-emptively at a given AKI stage.
Limitations
Sepsis-AKI microcirculatory decoupling, KDIGO staging, Furosemide Stress Test (FST), urine microscopy, and the AEIOU dialysis threshold framework.
Principles of convection vs diffusion, filtration fraction, delivered effluent dosing (20–25 mL/kg/h), Regional Citrate Anticoagulation, and citrate toxicity.