Regional Practice Variation in the Management of Renal Replacement Therapy Modalities in the STARRT-AKI Trial.

Introduction: The assess whether, in high-income countries, in the STandard vs. Accelerated initiation of Renal Replacement Therapy in Acute Kidney Injury (STARRT-AKI) trial, the management of the chosen initial renal replacement therapy modality varied by region and whether such variation was associated with different outcomes.

Methods: Post hoc analysis of the STARRT-AKI trial, including 142 ICUs in 13 countries. We evaluated 1,395 patients with severe AKI from North America, Europe, and Australia-New Zealand (ANZ) who received continuous renal replacement therapy (CRRT) as a first modality and 684 patients from North America and Europe who received intermittent hemodialysis (IHD) as a first modality.

Results: Among CRRT-first patients, femoral vascular access (p < 0.001) and citrate anticoagulation were more common in Europe and ANZ (p < 0.001) before and after adjustment for baseline characteristics. Treatment in ANZ was independently associated with a more negative fluid balance (p = 0.029), less frequent transition to IHD (p = 0.040), and lower CRRT dose-intensity (p = 0.012). Among IHD-first patients, compared to Europe, treatment in North America was independently associated with less use of femoral access, and greater net ultrafiltration rate.

Conclusion: At STARRT-AKI trial centers, there was significant region-dependent practice variation in the management of CRRT-first and IHD-first patients.