Cheryl Lee, MD

Background: Acute kidney injury (AKI) in the ICU is associated with high mortality. It is hypothesized that earlier initiation of RRT may benefit patients by controlling fluid overload and reducing metabolic stress caused by electrolyte and acid-base imbalances. However, prior studies have been conflicting, with the IDEAL-ICU study (2018) demonstrating no improvement in 90-day mortality with early RRT in septic shock.

Study design: Open-label randomized controlled trial.

Setting: 168 hospitals in 15 countries.

Synopsis: Of ICU patients with severe AKI, 3,019 were randomized to either early or standard initiation of RRT. Early RRT was defined as occurring within 12 hours of eligibility; in the standard-therapy group, RRT was delayed until specifically indicated or if there was no improvement after 72 hours. Those needing immediate renal replacement or deemed likely to recover without need for RRT were excluded in order to study only those in whom ideal timing of dialysis was uncertain. There was no difference in 90-day mortality between the groups (43.9% vs. 43.7%; P = .92). Early initiation did not improve length of ICU stay, ventilator-free days, days out of the hospital, or quality of life. The early-initiation patients experienced more adverse events related to RRT and were more likely to have continued dependence on RRT at 90 days (10.4% vs. 6.0% in standard initiation). Of note, approximately 40% of those randomized to standard initiation never required RRT.

Bottom line: This large, multicenter, well-conducted trial demonstrates no benefit for early initiation of RRT in critically ill patients.

Citation: STARRT-AKI investigators. Timing of initiation of renal-replacement therapy in acute kidney injury. N Engl J Med. 2020;383:240-51. doi: 10.1056/NEJMoa2000741.

Dr. Lee is a hospitalist at Northwestern Memorial Hospital and Lurie Children’s Hospital and assistant professor of medicine, Feinberg School of Medicine, all in Chicago.

Background: Acute kidney injury (AKI) in the ICU is associated with high mortality. It is hypothesized that earlier initiation of RRT may benefit patients by controlling fluid overload and reducing metabolic stress caused by electrolyte and acid-base imbalances. However, prior studies have been conflicting, with the IDEAL-ICU study (2018) demonstrating no improvement in 90-day mortality with early RRT in septic shock.

Study design: Open-label randomized controlled trial.

Setting: 168 hospitals in 15 countries.

Synopsis: Of ICU patients with severe AKI, 3,019 were randomized to either early or standard initiation of RRT. Early RRT was defined as occurring within 12 hours of eligibility; in the standard-therapy group, RRT was delayed until specifically indicated or if there was no improvement after 72 hours. Those needing immediate renal replacement or deemed likely to recover without need for RRT were excluded in order to study only those in whom ideal timing of dialysis was uncertain. There was no difference in 90-day mortality between the groups (43.9% vs. 43.7%; P = .92). Early initiation did not improve length of ICU stay, ventilator-free days, days out of the hospital, or quality of life. The early-initiation patients experienced more adverse events related to RRT and were more likely to have continued dependence on RRT at 90 days (10.4% vs. 6.0% in standard initiation). Of note, approximately 40% of those randomized to standard initiation never required RRT.

Bottom line: This large, multicenter, well-conducted trial demonstrates no benefit for early initiation of RRT in critically ill patients.

Citation: STARRT-AKI investigators. Timing of initiation of renal-replacement therapy in acute kidney injury. N Engl J Med. 2020;383:240-51. doi: 10.1056/NEJMoa2000741.

Dr. Lee is a hospitalist at Northwestern Memorial Hospital and Lurie Children’s Hospital and assistant professor of medicine, Feinberg School of Medicine, all in Chicago.

Background: Acute kidney injury (AKI) in the ICU is associated with high mortality. It is hypothesized that earlier initiation of RRT may benefit patients by controlling fluid overload and reducing metabolic stress caused by electrolyte and acid-base imbalances. However, prior studies have been conflicting, with the IDEAL-ICU study (2018) demonstrating no improvement in 90-day mortality with early RRT in septic shock.

Study design: Open-label randomized controlled trial.

Setting: 168 hospitals in 15 countries.

Synopsis: Of ICU patients with severe AKI, 3,019 were randomized to either early or standard initiation of RRT. Early RRT was defined as occurring within 12 hours of eligibility; in the standard-therapy group, RRT was delayed until specifically indicated or if there was no improvement after 72 hours. Those needing immediate renal replacement or deemed likely to recover without need for RRT were excluded in order to study only those in whom ideal timing of dialysis was uncertain. There was no difference in 90-day mortality between the groups (43.9% vs. 43.7%; P = .92). Early initiation did not improve length of ICU stay, ventilator-free days, days out of the hospital, or quality of life. The early-initiation patients experienced more adverse events related to RRT and were more likely to have continued dependence on RRT at 90 days (10.4% vs. 6.0% in standard initiation). Of note, approximately 40% of those randomized to standard initiation never required RRT.

Bottom line: This large, multicenter, well-conducted trial demonstrates no benefit for early initiation of RRT in critically ill patients.

Citation: STARRT-AKI investigators. Timing of initiation of renal-replacement therapy in acute kidney injury. N Engl J Med. 2020;383:240-51. doi: 10.1056/NEJMoa2000741.

Dr. Lee is a hospitalist at Northwestern Memorial Hospital and Lurie Children’s Hospital and assistant professor of medicine, Feinberg School of Medicine, all in Chicago.

Background: Prior studies have failed to show a benefit to earlier endoscopic intervention in acute GI bleeding. However, those studies were performed in all-comers without attention to the varying risk within the patient population.

Study design: Randomized controlled trial.

Setting: Single center in Hong Kong.

Synopsis: Patients at high risk for further bleeding or death by clinical score were randomized to endoscopy within 6 hours (“urgent endoscopy”), vs. the following day (“early endoscopy”), of GI consultation. Those who required immediate endoscopic intervention because of hemodynamic instability were excluded. All were prescribed proton-pump inhibitor drip, with the addition of vasoactive drugs and antibiotics if there was a suspected variceal bleed. There was no difference in 30-day mortality between the two groups – 8.9% with urgent endoscopy and 6.6% with early endoscopy (HR, 1.35; 95% CI, 0.72-2.54). There was no difference in length of hospital stay or the number of transfusions. Earlier endoscopy within 6 hours was associated with a higher number of actively bleeding lesions requiring intervention and a nonstatistical increase in recurrent bleeding within 30 days. It is believed that more time on proton-pump inhibitor infusion prior to endoscopy allows for stabilization of bleeds, thus requiring less intervention when endoscopy does occur.

Bottom line: Early endoscopy within 6 hours was not beneficial for those at high risk for rebleeding and death from upper GI bleed.

Citation: Lau JYW et al. Timing of endoscopy for acute upper gastrointestinal bleeding. N Engl J Med. 2020;382:1299-308. doi:10.1056/NEJMoa1912484.

Dr. Lee is a hospitalist at Northwestern Memorial Hospital and Lurie Children’s Hospital and assistant professor of medicine, Feinberg School of Medicine, all in Chicago.

Background: Prior studies have failed to show a benefit to earlier endoscopic intervention in acute GI bleeding. However, those studies were performed in all-comers without attention to the varying risk within the patient population.

Study design: Randomized controlled trial.

Setting: Single center in Hong Kong.

Synopsis: Patients at high risk for further bleeding or death by clinical score were randomized to endoscopy within 6 hours (“urgent endoscopy”), vs. the following day (“early endoscopy”), of GI consultation. Those who required immediate endoscopic intervention because of hemodynamic instability were excluded. All were prescribed proton-pump inhibitor drip, with the addition of vasoactive drugs and antibiotics if there was a suspected variceal bleed. There was no difference in 30-day mortality between the two groups – 8.9% with urgent endoscopy and 6.6% with early endoscopy (HR, 1.35; 95% CI, 0.72-2.54). There was no difference in length of hospital stay or the number of transfusions. Earlier endoscopy within 6 hours was associated with a higher number of actively bleeding lesions requiring intervention and a nonstatistical increase in recurrent bleeding within 30 days. It is believed that more time on proton-pump inhibitor infusion prior to endoscopy allows for stabilization of bleeds, thus requiring less intervention when endoscopy does occur.

Bottom line: Early endoscopy within 6 hours was not beneficial for those at high risk for rebleeding and death from upper GI bleed.

Citation: Lau JYW et al. Timing of endoscopy for acute upper gastrointestinal bleeding. N Engl J Med. 2020;382:1299-308. doi:10.1056/NEJMoa1912484.

Dr. Lee is a hospitalist at Northwestern Memorial Hospital and Lurie Children’s Hospital and assistant professor of medicine, Feinberg School of Medicine, all in Chicago.

Background: Prior studies have failed to show a benefit to earlier endoscopic intervention in acute GI bleeding. However, those studies were performed in all-comers without attention to the varying risk within the patient population.

Study design: Randomized controlled trial.

Setting: Single center in Hong Kong.

Synopsis: Patients at high risk for further bleeding or death by clinical score were randomized to endoscopy within 6 hours (“urgent endoscopy”), vs. the following day (“early endoscopy”), of GI consultation. Those who required immediate endoscopic intervention because of hemodynamic instability were excluded. All were prescribed proton-pump inhibitor drip, with the addition of vasoactive drugs and antibiotics if there was a suspected variceal bleed. There was no difference in 30-day mortality between the two groups – 8.9% with urgent endoscopy and 6.6% with early endoscopy (HR, 1.35; 95% CI, 0.72-2.54). There was no difference in length of hospital stay or the number of transfusions. Earlier endoscopy within 6 hours was associated with a higher number of actively bleeding lesions requiring intervention and a nonstatistical increase in recurrent bleeding within 30 days. It is believed that more time on proton-pump inhibitor infusion prior to endoscopy allows for stabilization of bleeds, thus requiring less intervention when endoscopy does occur.

Bottom line: Early endoscopy within 6 hours was not beneficial for those at high risk for rebleeding and death from upper GI bleed.

Citation: Lau JYW et al. Timing of endoscopy for acute upper gastrointestinal bleeding. N Engl J Med. 2020;382:1299-308. doi:10.1056/NEJMoa1912484.

Dr. Lee is a hospitalist at Northwestern Memorial Hospital and Lurie Children’s Hospital and assistant professor of medicine, Feinberg School of Medicine, all in Chicago.