Starting with intermittent haemodialysis in critical AKI was associated with higher mortality

Design

Multicentre, open-label, randomised non-inferiority trial, stopped early

Population

554 critically ill adults with AKI and an indication for renal replacement therapy (535 analysed)

Primary outcome

Major adverse kidney events (death, dialysis dependence or creatinine >25% above baseline) by day 90

Effect

78.1% vs 71.6% (risk difference 6.28 points, −1.22 to 13.79); 90-day death HR 1.30 (1.04–1.63)

ICRAKI was a multicentre, open-label, non-inferiority trial in France, published in NEJM on 14 October. Critically ill adults with acute kidney injury and an indication for renal replacement therapy were randomised to start with intermittent haemodialysis or continuous renal replacement therapy (CRRT).

The data monitoring committee stopped it early after repeated interim analyses showed a persistent mortality signal. In 535 analysed patients, death by day 90 was 63% with intermittent haemodialysis and 54% with CRRT. The composite of death, ongoing dialysis or poor renal recovery was 78% against 72%, and intermittent therapy failed to show non-inferiority. Hypotension was common in both groups.

Many units, including in India, choose intermittent haemodialysis because CRRT is costly and needs equipment and staff. This trial argues for CRRT as the first choice in the sickest patients where it is available. Early stopping can exaggerate effects, and the mortality difference was not the primary outcome, so the size of the gap is uncertain.

For clinicians outside the ICU, the message is simpler: a critically ill patient needing dialysis is better placed where continuous therapy can be offered.

• Prefer continuous renal replacement therapy as the starting mode for critically ill patients with AKI where it is available.
• Involve critical care early when a deteriorating ward patient may need dialysis.
• Where only intermittent haemodialysis is possible, plan for hypotension: slower ultrafiltration and close blood pressure monitoring.
• Mortality at 90 days exceeded 50% in both groups; discuss prognosis early with families.

Why it matters

It challenges the long-held view that the two modes are interchangeable for survival.

Don't overread it

The trial stopped early and death was not its primary outcome, so the true mortality difference may be smaller.

The statistics, in plain English

The hazard ratio for death of 1.30 (95% CI 1.04 to 1.63) means about 30% higher risk with intermittent dialysis, and the interval stays above 1. The primary composite difference of 6.3 points (−1.2 to 13.8) crosses zero, so the trial cannot call intermittent dialysis worse on that outcome, only not shown to be as good. Trials stopped early for a signal tend to overstate it.

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