Regional Practice Variation and Outcomes in the Standard Versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) Trial: A Post Hoc Secondary Analysis

Suvi T Vaara; Ary Serpa Neto; Rinaldo Bellomo; Neill K J Adhikari; Didier Dreyfuss; Martin Gallagher; Stephane Gaudry; Eric Hoste; Michael Joannidis; Ville Pettilä; Amanda Y Wang; Kianoush Kashani; Ron Wald; Sean M Bagshaw; Marlies Ostermann

doi:10.1097/CCE.0000000000001053

Regional Practice Variation and Outcomes in the Standard Versus Accelerated Initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) Trial: A Post Hoc Secondary Analysis

Crit Care Explor. 2024 Feb 19;6(2):e1053. doi: 10.1097/CCE.0000000000001053. eCollection 2024 Feb.

Authors

Suvi T Vaara¹, Ary Serpa Neto^{2

3

4

5}, Rinaldo Bellomo^{2

3

4

6

7}, Neill K J Adhikari^{8

9

10}, Didier Dreyfuss^{11

12}, Martin Gallagher^{13

14}, Stephane Gaudry^{11

15}, Eric Hoste¹⁶, Michael Joannidis¹⁷, Ville Pettilä¹, Amanda Y Wang^{13

14

18}, Kianoush Kashani¹⁹, Ron Wald^{20

21}, Sean M Bagshaw²², Marlies Ostermann²³

Affiliations

¹ Department of Perioperative and Intensive Care, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
² Australian and New Zealand Intensive Care Research Centre (ANZIC-RC), School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia.
³ Department of Critical Care, Melbourne Medical School, University of Melbourne, Austin Hospital, Melbourne, VIC, Australia.
⁴ Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.
⁵ Department of Critical Care Medicine, Hospital Israelita Albert Einstein, Sao Paulo, Brazil.
⁶ Data Analytics Research & Evaluation, Austin Hospital, Melbourne, VIC, Australia.
⁷ Department of Intensive Care, Royal Melbourne Hospital, Melbourne, VIC, Australia.
⁸ Department of Critical Care Medicine, Sunnybrook Health Sciences Centre, Toronto, ON, Canada.
⁹ Institute of Health Policy, Management and Evaluation, Dalla Lana School of Public Health, University of Toronto, Toronto, ON, Canada.
¹⁰ Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
¹¹ French National Institute of Health and Medical Research (INSERM), UMR_S1155, CORAKID, Hôpital Tenon, Sorbonne Université, Paris, France.
¹² Service de Médecine Intensive Réanimation, Hôpital Louis Mourier, Assistance Publique, Université de Paris-Cité, Paris, France.
¹³ South Western Sydney Clinical Campus, Faculty of Medicine & Health, University of New South Wales, New South Wales, NSW, Australia.
¹⁴ The George Institute for Global Health, University of New South Wales, New South Wales, Australia.
¹⁵ AP-HP, Hôpital Avicenne, Service de Réanimation Médico-Chirurgicale, UFR SMBH, Université Sorbonne Paris Nord, Bobigny, France.
¹⁶ Intensive Care Unit, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Ghent, Belgium.
¹⁷ Division of Intensive Care and Emergency Medicine, Department of Internal Medicine, Medical University Innsbruck, Innsbruck, Austria.
¹⁸ The Faculty of Medicine and Medical Sciences, Macquarie University, Sydney, NSW, Australia.
¹⁹ Division of Nephrology and Hypertension, Division of Pulmonary and Critical Care Medicine, Department of Medicine, Mayo Clinic College of Medicine, Rochester, MN.
²⁰ Medicine Program and Li Ka Shing Knowledge Institute, St. Michael's Hospital, Unity Health Toronto, Toronto, ON, Canada.
²¹ Division of Nephrology, St. Michael's Hospital and the University of Toronto and the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
²² Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada.
²³ Department of Critical Care Medicine, King's College London, Guy's & St Thomas' Hospital, London, United Kingdom.

Abstract

Objectives: Among patients with severe acute kidney injury (AKI) admitted to the ICU in high-income countries, regional practice variations for fluid balance (FB) management, timing, and choice of renal replacement therapy (RRT) modality may be significant.

Design: Secondary post hoc analysis of the STandard vs. Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial (ClinicalTrials.gov number NCT02568722).

Setting: One hundred-fifty-three ICUs in 13 countries.

Patients: Altogether 2693 critically ill patients with AKI, of whom 994 were North American, 1143 European, and 556 from Australia and New Zealand (ANZ).

Interventions: None.

Measurements and main results: Total mean FB to a maximum of 14 days was +7199 mL in North America, +5641 mL in Europe, and +2211 mL in ANZ (p < 0.001). The median time to RRT initiation among patients allocated to the standard strategy was longest in Europe compared with North America and ANZ (p < 0.001; p < 0.001). Continuous RRT was the initial RRT modality in 60.8% of patients in North America and 56.8% of patients in Europe, compared with 96.4% of patients in ANZ (p < 0.001). After adjustment for predefined baseline characteristics, compared with North American and European patients, those in ANZ were more likely to survive to ICU (p < 0.001) and hospital discharge (p < 0.001) and to 90 days (for ANZ vs. Europe: risk difference [RD], -11.3%; 95% CI, -17.7% to -4.8%; p < 0.001 and for ANZ vs. North America: RD, -10.3%; 95% CI, -17.5% to -3.1%; p = 0.007).

Conclusions: Among STARRT-AKI trial centers, significant regional practice variation exists regarding FB, timing of initiation of RRT, and initial use of continuous RRT. After adjustment, such practice variation was associated with lower ICU and hospital stay and 90-day mortality among ANZ patients compared with other regions.

Keywords: acute kidney injury; continuous renal replacement therapy; fluid balance; intermittent hemodialysis; outcomes; randomized controlled trial.

Associated data

ClinicalTrials.gov/NCT02568722