LandmarkRCT

STARRT-AKI

Timing of Initiation of Renal-Replacement Therapy in Acute Kidney Injury

New England Journal of Medicine, 2020 · International, multicenter, randomized controlled trial — the largest RRT-timing trial to date.

Clinical question

In critically ill adults with severe AKI, does an accelerated RRT initiation strategy improve 90-day survival compared with a standard, watchful-waiting strategy?

Population: 3,019 critically ill adults with severe AKI (2,927 analyzed for the primary outcome), across sites in multiple countries.
Intervention: Accelerated strategy: RRT initiated promptly after meeting eligibility, generally within 12 hours.
Comparator: Standard strategy: RRT deferred unless a conventional indication developed, or AKI persisted beyond 72 hours.
Primary outcome: 90-day all-cause mortality.
Secondary outcomes: RRT dependence at 90 days.
Adverse events (including hypotension and arrhythmia).
Result: No significant difference in 90-day mortality between accelerated and standard strategies. A substantial proportion (roughly 38%) of the standard-strategy group avoided RRT entirely without a mortality penalty. The accelerated strategy was associated with more adverse events.

What the trial found

In the largest and most rigorously powered trial of RRT timing to date, an accelerated initiation strategy did not improve 90-day survival compared with watchful waiting, and watchful waiting safely avoided RRT altogether in a large minority of patients.

Current guideline position

The weight of evidence (AKIKI, IDEAL-ICU, STARRT-AKI, all neutral or favoring watchful waiting, against ELAIN's isolated positive result) supports initiating RRT based on a clinical indication rather than a fixed AKI stage — this evidence predates and is expected to inform the still-in-draft KDIGO 2026 RRT timing guidance.

Clinical interpretation

STARRT-AKI is the strongest single piece of evidence against routine early/accelerated RRT initiation in AKI without a specific indication — it reinforces AKIKI and IDEAL-ICU, and its size and rigor argue against generalizing ELAIN's earlier, smaller, single-center positive result to general practice.

Limitations

Accelerated strategy was associated with more adverse events (e.g. hypotension), a real trade-off against any hypothetical benefit.
Excluded patients with an immediate life-threatening indication for RRT.

High certainty

Clinical Context & Relevant Topics (2)

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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