Abstract
Purpose
The effect of renal replacement therapy (RRT) in comatose patients with acute kidney injury (AKI) remains unclear. We compared two RRT initiation strategies on the probability of awakening in comatose patients with severe AKI.
Methods
We conducted a post hoc analysis of a trial comparing two delayed RRT initiation strategies in patients with severe AKI. Patients were monitored until they had oliguria for more than 72 h and/or blood urea nitrogen higher than 112 mg/dL and then randomized to a delayed strategy (RRT initiated after randomization) or a more-delayed one (RRT initiated if complication occurred or when blood urea nitrogen exceeded 140 mg/dL). We included only comatose patients (Richmond Agitation-Sedation scale [RASS] < − 3), irrespective of sedation, at randomization. A multi-state model was built, defining five mutually exclusive states: death, coma (RASS < − 3), incomplete awakening (RASS [− 3; − 2]), awakening (RASS [− 1; + 1] two consecutive days), and agitation (RASS > + 1). Primary outcome was the transition from coma to awakening during 28 days after randomization.
Results
A total of 168 comatose patients (90 delayed and 78 more-delayed) underwent randomization. The transition intensity from coma to awakening was lower in the more-delayed group (hazard ratio [HR] = 0.36 [0.17–0.78]; p = 0.010). Time spent awake was 10.11 days [8.11–12.15] and 7.63 days [5.57–9.64] in the delayed and the more-delayed groups, respectively. Two sensitivity analyses were performed based on sedation status and sedation practices across centers, yielding comparable results.
Conclusion
In comatose patients with severe AKI, a more-delayed RRT initiation strategy resulted in a lower chance of transitioning from coma to awakening.
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Data availability
Anonymous participant data is available under specific conditions. Proposals will be reviewed and approved by the sponsor, scientific committee and staff on the basis of scientific merit and absence of competing interests. Once the proposal has been approved, data can be transferred through a secure online platform after the signing of a data access agreement and a confidentiality agreement.
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Acknowledgements
We thank patients and their surrogates and all medical and nursing teams. The AKIKI 2 trial was promoted by the Assistance Publique—Hôpitaux de Paris and funded by a grant of the French Ministry of Health (Programme Hospitalier de Recherche Clinique 2016; AOM16278).
Funding
This article is funded by Ministère de l’Enseignement Supérieur et de la Recherche, AOM16278, Stephane Gaudry.
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TR, DH, SL, DD, SG, and RS were responsible for the design, analyzing and writing the manuscript. GL, SM, DTB, BLC,BP, NdP, SBe, AC, AR, MB, JBa, GC, JBo, EC, NC, SBa, CV, JMF,DT, EB,KL, NA, SGr, ML, GL, SN, FP, JM, KA, GG, KK, GT, LA BR, CC, PA, JR, JDR, and JPQ were responsible for recruitment and clinical care of the patients. All authors reviewed and approved the final version of the manuscript.
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Rambaud, T., Hajage, D., Dreyfuss, D. et al. Renal replacement therapy initiation strategies in comatose patients with severe acute kidney injury: a secondary analysis of a multicenter randomized controlled trial. Intensive Care Med 50, 385–394 (2024). https://doi.org/10.1007/s00134-024-07339-1
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DOI: https://doi.org/10.1007/s00134-024-07339-1