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The STARRT-AKI Research Program

Renal replacement therapy in the critically ill – early the better?

Acute kidney injury (AKI) is a common and increasingly encountered complication of critical illness, occurring in more than half of all patients admitted to the intensive care unit (ICU). Many will develop more severe AKI or overt complications related to AKI, acute renal replacement therapy (RRT) is often needed and commenced.

The issue of when to ideally start acute RRT for a critically ill patient with AKI has troubled clinicians for decades. The optimal threshold for when and in whom to commence RRT remains uncertain and is currently recognized as a top research priority in the field of critical care nephrology. Among patients faced with life-threatening complications of AKI such as severe hyperkalemia, marked metabolic acidosis or fluid overload, the decision to urgently start RRT is generally unequivocal. However, more recent data have suggested the occurrence of life-threatening complications attributable to AKI are less common reasons for why critically ill patients with AKI receive RRT. In the absence of these overt or impending life-threatening complications, the optimal time to start RRT in AKI is largely unknown. Not surprisingly, given this knowledge gap, there remains wide variation in clinical practice for when acute RRT in initiated in critical care settings. Unfortunately, this variation in practice likely contributes to inconsistent and suboptimal quality of care.

The STARRT-AKI research program lead by Sean Bagshaw from the University of Alberta (Edmonton) and Ron Wald from St. Michael’s Hospital (Toronto) under the umbrella of the CCCTG aims to investigate whether an early accelerated strategy to starting acute RRT in critically ill patients with severe AKI compared with a more conservative strategy of “watchful waiting” will translate into improved outcomes for patients and reduced health services use.

The STARRT-AKI team have performed a series of preliminary studies to frame the scope of this issue and support the conduct of a large randomized trial intended to guide clinical care on this issue. In 2015, the STARRT-AKI team published the results of the pilot study in the journal Kidney International. This pilot study enrolled 101 critically ill patients with severe acute kidney injury established the feasibility of performing a larger international trial to provide definitive evidence to guide clinical care on this issue.

The STARRT-AKI study (ClinicalTrials.gov), which is currently underway, aims to enroll 2,866 patients from numerous centers across Canada and internationally, including the United States, Europe, Australia and New Zealand.