Early versus late renal replacement therapy in acute kidney injury the search for a definition of timing continues.docVIP

Bannard-Smith and Mousdale Critical Care 2011, 15:437 /content/15/4/437 LET TER Early versus late renal replacement therapy in acute kidney injury: the search for a de? nition of timing continues Jonathan Bannard-Smith* and Stephen Mousdale See related research by Karvellas et al., /content/15/1/R72 We read with interest the systematic review by Karvellas and colleagues on early versus late renal replacement therapy (RRT) in critically ill patients with acute kidney injury (AK e authors rightly cite enormous heterogeneity between the 15 studies reviewed as a key concern. We would like to focus on the varied approach and lack of consensus in de? ning early and late initiation of RRT, as all of the 15 studies quote di? erent de? nitions in their methods. Even those utilising similar markers and criteria for AKI – for example, the RIFLE criteria [2] (two studies) or blood urea and nitrogen (four studies) – utilised and interpreted them in very di? erent ways when distinguishing early and late initiation of RRT. None of the studies reviewed used the Acute Kidney Injury Network (AKIN) criteria [3]. Having applied the AKIN criteria to data from our 20-bed critical care unit for all patients receiving RRT in 2009 ( n = 158), we also failed to show RRT initiated at an early stage of AKI to be of bene? t in terms of critical care or hospital survival. Figure 1 shows a higher rate of hospital mortality in patients with AKIN stage 1 AKI (P = 0.01). Patient Figure 1. Hospital survival based on acute kidney injury staging. Histogram for hospital survival based on acute kidney injury (AKI) staging according to Acute Kidney Injury Network criteria [3] (n = 143). RRT, renal replacement therapy. charac teristics including age, sex and Acute Physiology colleagues’ conclusions, surely the matter of greatest and Chronic Health Evaluation scores were similar across urgency