The AKIKI Trial

Aside from the fact that this trial has a really cool acronym, I thought this trial deserved a blog because the results are practice-changing (or practice-confirming if you’re already practicing the delayed strategy.)  Published ahead of print in NEJM.

Artificial Kidney Initiation in Kidney Injury trial (AKIKI)

Compared two groups:

  • early initiation of renal-replacement therapy (early-strategy group)
  • delayed initiation of renal-replacement therapy (delayed-strategy group)

Primary outcome:

  • overall survival


Secondary outcomes:

  • receipt of renal-replacement therapy at least once with the delayed strategy
  • renal-replacement therapy–free days
  • dialysis catheter–free days
  • mechanical ventilation–free days
  • vasopressor therapy–free days
  • Sepsis-related Organ Failure Assessment (SOFA) score at day 3 and day 7
  • vital status at day 28
  • length of stay in the intensive care unit and in the hospital
  • proportion of patients with treatment limitations (i.e., withholding or withdrawal of treatment)
  • nosocomial infections
  • complications potentially related to acute kidney injury or renal-replacement therapy


Results of the study:

  • 5528 patients eligible
  • 620 patients underwent randomization
    • 312 were assigned to the early-strategy group
    • 308 were assigned to the delayed-strategy group
  • early-strategy group underwent first renal-replacement therapy session within a median of 2 hours after randomization and within a median of 4.3 hours after documentation of stage 3 acute kidney injury and of the fulfillment of other inclusion criteria
  • 157 patients (51%) received renal-replacement therapy in the delayed-strategy group within a median of 57 hours after randomization, median interval between the occurrence of at least one criterion mandating renal-replacement therapy and its initiation was 4.7 hours
    • 49% in delayed-strategy group did not receive RRT
  • rate of catheter-related bloodstream infections was higher in early-strategy group
  • diuresis occurred earlier in the delayed strategy group
  • No difference in mortality, delayed strategy averted the need for RRT in an appreciable number of patients.



Take-home points:

  • do not interpret study as “wait and see” approach is safe for all patients
  • careful surveillance is mandatory when deciding to delay RRT in patients with severe AKI



Gaudry, Stéphane et al. “Initiation Strategies For Renal-Replacement Therapy In The Intensive Care Unit”. New England Journal of Medicine (2016): n. pag. Web. 19 May 2016.



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