LandmarkRCT

IDEAL-ICU

Timing of Renal-Replacement Therapy in Patients with Acute Kidney Injury and Sepsis

New England Journal of Medicine, 2018 · Multicenter (French, 29 sites), randomized controlled trial, stopped early for futility.

Clinical question

In patients with septic shock and severe (RIFLE 'Failure' stage) AKI, does early RRT initiation improve 90-day survival compared with a delayed strategy?

Population: 488 critically ill adults with septic shock and RIFLE 'Failure'-stage AKI.
Intervention: Early strategy: RRT initiated within 12 hours of meeting Failure-stage criteria.
Comparator: Delayed strategy: RRT initiated after 48 hours if renal recovery had not occurred, or immediately if a standard urgent indication developed.
Primary outcome: 90-day all-cause mortality.
Result: No significant difference in 90-day mortality between early and delayed strategies; the trial was stopped early for futility.

What the trial found

In patients with septic shock and severe AKI specifically, early RRT initiation did not improve 90-day survival compared with a delayed, indication-based strategy.

Current guideline position

Consistent with AKIKI and STARRT-AKI, and contributes to current practice favoring indication-based rather than stage-based RRT initiation timing, including in septic AKI specifically.

Clinical interpretation

IDEAL-ICU extends the AKIKI finding to a septic-shock-specific population and reinforces that routine early RRT does not improve survival even in this higher-acuity group — supporting watchful waiting with RRT reserved for a defined indication rather than initiated pre-emptively based on AKI stage alone.

Limitations

Stopped early for futility, which reduces power to detect a smaller true effect.
Restricted to septic shock with Failure-stage AKI, so may not generalize to non-septic AKI.

High certainty

Clinical Context & Relevant Topics (3)

Disease Reference

Acute Kidney Injury in Critical Care

Sepsis-AKI microcirculatory decoupling, KDIGO staging, Furosemide Stress Test (FST), urine microscopy, and the AEIOU dialysis threshold framework.

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Continuous Renal Replacement Therapy (CRRT)

Principles of convection vs diffusion, filtration fraction, delivered effluent dosing (20–25 mL/kg/h), Regional Citrate Anticoagulation, and citrate toxicity.

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Septic Shock

The subset of sepsis with profound circulatory and cellular/metabolic abnormality — clinically identified by a vasopressor requirement to maintain MAP ≥ 65 mmHg plus lactate > 2 mmol/L despite adequate fluid resuscitation.

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