Welcome to que digo conversations in Nephrology. This episode is titled deciding when and who should start a cute. Dialysis from evidence to bedside practice. Here's your host. Dr. Ravi Mehta. There are important decisions to be made regarding when and who should start a kid. Dialysis, how the conditions take this from evidence to bedside practice. Hello and welcome to Katie, go conversation Nephrology. I'm dr.
Avi. Metha professor of medicine at the University of California in San Diego and joining me to discuss the ins and out of starting a coup Dallas's is dr. Marley's, Osterman. Dr. Osterman is a consultant in critical care and a prodigy at guy's and St. Thomas Foundation. Trust of London and her clinical research, interests include acute, kidney injury. In the critically ill, including biomarkers, and long-term complications, and all aspects, related to acute.
Kidney replacement therapy. Dr. Osterman. Welcome to the program. Thank you. Professor media for this kind introduction. It's a great honor to participate in today's discussion about timing of acute. Dialysis such an important topic in routine clinical practice. So let's get started. There's been considerable interest in defining the optimal timing for starting, dialysis and critically ill patients. Why is This an area of controversy. That's a very good question. I'm afraid. Acute.
Kidney injury is very common in critically ill patients in the Intensive Care Unit and patients, who develop acute kidney injury often spend longer in hospital and have a much higher risk of complications. It's a particularly high risk of dying in those who need a cute dialysis. So, on the one hand acute paralysis can be life-saving, but I'm afraid it also has adverse effects and can cause harm and we as clinicians we want to avoid harm if possible.
So with regards to acute, dialysis, we grapple with the decision when to start. If we start too early, we may prevent the complications of acute kidney injury, but we will. Give a treatment to patients who don't actually need it. And if we wait too long, the treatment May no longer be beneficial. So this harm versus benefit question is a real challenge in clinical practice when caring for an individual patient?
Fortunately, in the last few years, a lot of Trials have been published and a lot of Publications have given us more insight and important results and findings. So what have these recent trials on timing analysis. Shown us that can help us guide clinical application. We've had a lot of Publications including five Landmark trials, and I'll just mention them briefly. We had the Elaine trial, a Kiki, wanted a key to Ideal ICU and start Aki. These are Landmark tried in the
field of critic, an apology. They all explored timing of acute paralysis, but they addressed, this question from different perspectives. So, for instance, the Elaine trial was a The center study with the aim to find out whether starting acute Dallas's in patients with moderate acute. Kidney injury could reduce mortality.
And indeed the trial showed a significantly lower 90-day mortality in patients, who receive dialysis treatment earlier, in contrast, the a Kiki and ideal ICU tries for multicenter studies, which explored the question is it safe to wait? They enrolled patients with more severe. Acute kidney injury. And showed that 60 or 90 day mortality, was no different in patients who had received a cute analysis. Later compared to those who had received the cute dialysis, much
earlier importantly. They also found that acute paralysis could be avoided in a large number of patients who had been randomized to the delayed arm. However, should be mentioned, that mortality was higher. If patients in the delayed arm actually needed a cute dog. Treatment. And then we have these start Aki trial which is today the largest study with more than 3,000 patients from 168, different icus from 15 countries.
And this study focused on patients where clinicians had equipoise and had no objections to either accelerated or delayed initiation. We study showed no difference in 90-day. Mortality between the Accelerated versus standard initiation group, like the previous two studies. It also showed that acute paralysis could be avoided in almost 40 percent of patients and importantly, they highlighted some harm from
starting dialysis early. There was a higher risk of dialysis dependence at 90 days and there were more Adverse Events in the accelerated group. And overall. There was no obvious benefit from starting a cute doll. This earlier. So this then brings us to the next question. How long can you wait? And this was a question explored in the icky to trial? Patients with severe, acute kidney injury and oliguria or uremia were randomized to delayed or very delayed
initiation of dialysis. The trial showed that again, Dallas is could be avoided if you waited for longer, but 60-day mortality was higher. So together.
These trials have given us important information and explored the question from different angles, but they have still not giving us enough information to manage an individual patient at the bedside because we still do not know which patient actually needs acute paralysis and who can be managed conservatively in all studies be criteria for either early or late initiation was based on serum creatinine or severity of acute, kidney injury, but in real life at the
bedside, there are many other Area in fact, acute paralysis is a form of organ support, which we use to prevent fluid overload or normalized metabolic derangements or correct fluid overload. And so we clearly need more information at the bedside to guide us. Dr. Osterman. You're in a very experienced clinician and these trials, as you've pointed out, have not been fully comprehensive and telling us what we need.
So what are the most relevant parameters that influence your In on who you offer dialysis to when you start and when you stopped, my main aim is to give treatments to patients who will benefit from them and to avoid treatments that may either cause more harm than benefits and Q. Dallas is no exception. So I view acute paralysis as a form of kidney support and I want to start it and offer it to patients who are in whom King.
Any function is not sufficient to cope with the complications including metabolic derangements or fluid overload and I want to start it before the kidneys actually fail completely and therefore my Approach consists of repeated assessments and evaluation of the trajectories and an assessment of the future, including the next 12-24 hours per day.
None of what may happen and looking at these Trends and predicting whether patients will come to harm from the metabolic derangement or the accumulation of fluid guides me. So if patients are getting worse and fluid is building up and metabolic derangements are contributing to their condition and acute paralysis is in line with the patient's wishes and their overall treatment goal. Then I start from Gardeners of
the level of creatinine. I hope this demonstrates that there are many more factors than just creating it alone or stage of acute kidney injury, which guide and determine our management at the bedside. And it became very clear during the recent pandemic, but we may need to modify our general approach. When dealing with sick patients with acute, kidney injury for those just tuning in. You're listening to Katy. Your conversation in a prodigy.
Our topic today is deciding when and who should start a cute dialysis from evidence to bedside practice. I'm dr. Avi Mehta and I'm speaking with dr. Molly saw Steven. Dr. Osterman has your experience with managing patients change during the covid-19 pandemic. And if so in what way, I'm afraid during the pandemic, we had to change our approach to
acute Paralysis on many fronts. We like many colleagues facing Unexpected challenges, including reduced, dialysis capacity, unexpected Supply problems and a major shortage of nursing staff. And the first thing we learned was that there are at least two key processes that influence timing of acute Paralysis on the one hand. There is a decision process which focuses on the medical decision, but a patient needs
dialysis. And then there are the logistics and they certainly influence and impact timing. And these challenges forced us to adapt our practice. We obviously recruited one nurses. We expanded the dialysis modalities and use different types of dialysis. We even produce dialysis fluid and house to overcome some of the challenges. We also changed our approach to timing and we carefully assessed and reassessed which patient needed dialysis urgently.
We always ask the question. Question, whether it was safe to wait, without causing harm, whether there are any potential Alternatives. And then, lastly, whether we actually had the necessary kid and the nurses available to deliver Reno, replace dialysis treatment. Overall. The aim was to deliver the greatest good for the greatest number of patients. I'm very pleased. But we've recovered from this
period. And now, we are back to business as usual, which means a more personalized approach to timing of Dallas has so, what additional information is needed currently to help us improve care of patients. In the setting, what should conditions due to currently manage their patients? And are there. Any final messages you'd like to leave with our listeners?
My key messages to emphasize that acute, dialysis is a form of support therapy, which should be considered before kidney function, actually fails completely, and the optimal time varies from Patient to Patient. And to deliver this form of personalized medicine, taking into account, all the various aspects from metabolic derangement and fluid accumulation to potential. Trajectories means that we need more diagnostic tools and techniques to come to the right
decision. And as I already mentioned, it's clearly important that we all work together. And communicate, well with all the relevant people caring for patients including staff and the team delivering acute paralysis in order to devoid delays. After decision, in favor of the queue Dallas has been made. I also want to highlight again that acute paralysis is delivered and monitored very
differently across the world. I mean, speaking to colleagues, it's clear that we all use different quality metrics and I think It would be nice for us to agree, some quality indicators so that we can at least have similar standards and put Improvement projects in place. And then lastly, I would plead have an update of the existing Official Guidelines because none of them have included the data of the recent studies and randomized, controlled trials. With that in mind.
I was very pleased to hear that KD go is making preparation for a State of the que digo guideline. That's a great way to round out our discussion today. I would like to thank my guests. Dr. Molly's Osterman for joining me. Dr. Osterman. It was great. Having you on the program. It's been a great honor to participate.
And I hope today's discussion has highlighted some of the ongoing challenges but also the enormous advances and progress made in the last 10 years since the release of the que digo. Valid in 2012. I'm dr. Avi Mehta. To access this and other episodes in the series visit que digo dot org slash podcast. Thanks for listening. This episode of que digo conversations in Nephrology was provided by KD go and supported by Baxter Healthcare.