Dialysis Dependence in Standard Versus Accelerated Initiation of Kidney Replacement Therapy in Acute Kidney Injury: A Post-Hoc Analysis

ompared to a standard strategy. However, it is unclear whether this difference exists among participants who likely would have been treated with KRT in usual practice. Methods: Secondary analysis of the STARRT-AKI randomized controlled trial, analyzing participants who received more than the median number of days of KRT, which served as a proxy for high probability of requiring KRT under usual practice. Two sensitivity analyses redefined the cohort as 1) those with ≥24 hours of oliguria who received KRT and 2) those who received any RT. Using the same statistical approach Kas the original trial, we calculated unadjusted relative risks with 95% confidence intervals (CI) for the exposure of randomized KRT initiation strategy (accelerated vs. standard) on the outcome of KRT dependence at 90 days among survivors. Results: Among the 1,184 participants who received ≥six days of KRT (670 and 514 in the accelerated and standard arms, respectively), baseline characteristics remained balanced between treatment arms. The relative risk of KRT dependence at 90 days was attenuated and non-significant: 1.21 (95% CI 0.84-1.78), compared to 1.74 (95% CI 1.24-2.43) in the overall trial. Results were similar in sensitivity analyses. Conclusions: Among patients who likely would have been treated with KRT in usual practice, there was no significant difference in 90-day KRT dependence among survivors between those randomized to the accelerated and standard KRT initiation strategies. These results suggest that the harm of long-term KRT dependence may be largely due to KRT initiation (vs never initiation) rather than earlier initiation. Copyright © 2025 by the American Society of Nephrology...