Starting with intermittent haemodialysis in ICU acute kidney injury was linked to higher 90-day mortality

Design

Multicentre, open-label, randomised non-inferiority trial (ICRAKI), stopped early

Population

554 critically ill adults in France with AKI and an indication for renal replacement therapy

Primary outcome

Major adverse kidney events by day 90

Effect

78.1% vs 71.6% (risk difference 6.3 points, 95% CI −1.2 to 13.8); 90-day death HR 1.30 (1.04 to 1.63)

ICRAKI randomised critically ill adults with acute kidney injury who needed renal replacement therapy to start with either intermittent haemodialysis or continuous therapy. The question was whether intermittent dialysis was no worse.

The data monitoring committee stopped the trial after repeated interim analyses showed more deaths with intermittent haemodialysis. By day 90, 63% had died in that group against 54% with continuous therapy. The composite kidney outcome was also worse with intermittent dialysis, but not significantly so, and non-inferiority was not shown.

Earlier trials and meta-analyses found no difference between modalities, so this is a change. Trials stopped early can exaggerate effects, and the open-label design matters. Still, for units that can offer continuous therapy, the safer default is now harder to argue against.

• Death by day 90 was 63% with intermittent haemodialysis and 54% with continuous therapy.
• Intermittent haemodialysis failed to show non-inferiority on the composite of death, dialysis dependence or persistent kidney dysfunction.
• Hypotension rates were similar, about two thirds in each group.
• Where only intermittent dialysis is available, slower, longer sessions are a common workaround.
• Discuss modality with the nephrology and intensive care teams at the time of starting.

Why it matters

Many units treat the two modalities as interchangeable; this trial is the first in years to suggest the choice may affect survival.

Don't overread it

The trial stopped early, and the kidney composite did not differ significantly; early-stopped trials tend to overstate effects.

The statistics, in plain English

A hazard ratio of 1.30 means deaths occurred about 30% faster with intermittent dialysis; the interval from 1.04 to 1.63 does not cross 1. The kidney composite's interval does cross zero, so that difference is uncertain.

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