• Thomas Rambaud, David Hajage, Didier Dreyfuss, Saïd Lebbah, Laurent Martin-Lefevre, Guillaume Louis, Sébastien Moschietto, Dimitri Titeca-Beauport, Béatrice La Combe, Bertrand Pons, Nicolas De Prost, Sébastien Besset, Alain Combes, Adrien Robine, Marion Beuzelin, Julio Badie, Guillaume Chevrel, Julien Bohe, Elisabeth Coupez, Nicolas Chudeau, Saber Barbar, Christophe Vinsonneau, Jean-Marie Forel, Didier Thevenin, Eric Boulet, Karim Lakhal, Nadia Aissaoui, Steven Grange, Marc Leone, Guillaume Lacave, Saad Nseir, Florent Poirson, Julien Mayaux, Karim Ashenoune, Guillaume Geri, Kada Klouche, Guillaume Thiery, Laurent Argaud, Bertrand Rozec, Cyril Cadoz, Pascal Andreu, Jean Reignier, Jean-Damien Ricard, QuenotJean-PierreJPDepartment of Intensive Care, François Mitterrand University Hospital, Dijon, France.NSERM CIC 1432, Clinical Epidemiology, University of Burgundy, Dijon, France., Romain Sonneville, and Stéphane Gaudry.
• Département de Réanimation Médico-Chirurgicale, APHP Hôpital Avicenne, Bobigny, France.
• Intensive Care Med. 2024 Mar 1; 50 (3): 385394385-394.

PurposeThe effect of renal replacement therapy (RRT) in comatose patients with acute kidney injury (AKI) remains unclear. We compared two RRT initiation strategies on the probability of awakening in comatose patients with severe AKI.MethodsWe conducted a post hoc analysis of a trial comparing two delayed RRT initiation strategies in patients with severe AKI. Patients were monitored until they had oliguria for more than 72 h and/or blood urea nitrogen higher than 112 mg/dL and then randomized to a delayed strategy (RRT initiated after randomization) or a more-delayed one (RRT initiated if complication occurred or when blood urea nitrogen exceeded 140 mg/dL). We included only comatose patients (Richmond Agitation-Sedation scale [RASS] < - 3), irrespective of sedation, at randomization. A multi-state model was built, defining five mutually exclusive states: death, coma (RASS < - 3), incomplete awakening (RASS [- 3; - 2]), awakening (RASS [- 1; + 1] two consecutive days), and agitation (RASS >  + 1). Primary outcome was the transition from coma to awakening during 28 days after randomization.ResultsA total of 168 comatose patients (90 delayed and 78 more-delayed) underwent randomization. The transition intensity from coma to awakening was lower in the more-delayed group (hazard ratio [HR] = 0.36 [0.17-0.78]; p = 0.010). Time spent awake was 10.11 days [8.11-12.15] and 7.63 days [5.57-9.64] in the delayed and the more-delayed groups, respectively. Two sensitivity analyses were performed based on sedation status and sedation practices across centers, yielding comparable results.ConclusionIn comatose patients with severe AKI, a more-delayed RRT initiation strategy resulted in a lower chance of transitioning from coma to awakening.© 2024. Springer-Verlag GmbH Germany, part of Springer Nature.

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