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Welcome to que digo 
conversations in Nephrology. 

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This episode is titled deciding 
when and who should start a 

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cute. 
Dialysis from evidence to 

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bedside practice. 
Here's your host. 

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Dr. Ravi Mehta. 
There are important decisions to

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be made regarding when and who 
should start a kid. 

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Dialysis, how the conditions 
take this from evidence to 

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bedside practice. 
Hello and welcome to Katie, go 

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conversation Nephrology. 
I'm dr. 

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Avi. 
Metha professor of medicine at 

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the University of California in 
San Diego and joining me to 

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discuss the ins and out of 
starting a coup Dallas's is dr. 

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Marley's, Osterman. 
Dr. Osterman is a consultant in 

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critical care and a prodigy at 
guy's and St. 

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Thomas Foundation. 
Trust of London and her clinical

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research, interests include 
acute, kidney injury. 

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In the critically ill, including
biomarkers, and long-term 

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complications, and all aspects, 
related to acute. 

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Kidney replacement therapy. 
Dr. Osterman. 

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Welcome to the program. 
Thank you. 

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Professor media for this kind 
introduction. 

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It's a great honor to 
participate in today's 

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discussion about timing of 
acute. 

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Dialysis such an important topic
in routine clinical practice. 

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So let's get started. 
There's been considerable 

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interest in defining the optimal
timing for starting, dialysis 

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and critically ill patients. 
Why is This an area of 

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controversy. 
That's a very good question. 

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I'm afraid. 
Acute. 

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Kidney injury is very common in 
critically ill patients in the 

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Intensive Care Unit and 
patients, who develop acute 

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kidney injury often spend longer
in hospital and have a much 

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higher risk of complications. 
It's a particularly high risk of

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dying in those who need a cute 
dialysis. 

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So, on the one hand acute 
paralysis can be life-saving, 

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but I'm afraid it also has 
adverse effects and can cause 

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harm and we as clinicians we 
want to avoid harm if possible. 

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So with regards to acute, 
dialysis, we grapple with the 

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decision when to start. 
If we start too early, we may 

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prevent the complications of 
acute kidney injury, but we 

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will. 
Give a treatment to patients who

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don't actually need it. 
And if we wait too long, the 

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treatment May no longer be 
beneficial. 

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So this harm versus benefit 
question is a real challenge in 

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clinical practice when caring 
for an individual patient? 

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Fortunately, in the last few 
years, a lot of Trials have been

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published and a lot of 
Publications have given us more 

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insight and important results 
and findings. 

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So what have these recent trials
on timing analysis. 

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Shown us that can help us guide 
clinical application. 

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We've had a lot of Publications 
including five Landmark trials, 

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and I'll just mention them 
briefly. 

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We had the Elaine trial, a Kiki,
wanted a key to Ideal ICU and 

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start Aki. 
These are Landmark tried in the 

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field of critic, an apology. 
They all explored timing of 

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acute paralysis, but they 
addressed, this question from 

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different perspectives. 
So, for instance, the Elaine 

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trial was a The center study 
with the aim to find out whether

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starting acute Dallas's in 
patients with moderate acute. 

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Kidney injury could reduce 
mortality. 

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And indeed the trial showed a 
significantly lower 90-day 

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mortality in patients, who 
receive dialysis treatment 

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earlier, in contrast, the a Kiki
and ideal ICU tries for 

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multicenter studies, which 
explored the question is it safe

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to wait? 
They enrolled patients with more

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severe. 
Acute kidney injury. 

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And showed that 60 or 90 day 
mortality, was no different in 

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patients who had received a cute
analysis. 

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Later compared to those who had 
received the cute dialysis, much

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earlier importantly. 
They also found that acute 

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paralysis could be avoided in a 
large number of patients who had

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been randomized to the delayed 
arm. 

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However, should be mentioned, 
that mortality was higher. 

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If patients in the delayed arm 
actually needed a cute dog. 

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Treatment. 
And then we have these start Aki

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trial which is today the largest
study with more than 3,000 

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patients from 168, different 
icus from 15 countries. 

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And this study focused on 
patients where clinicians had 

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equipoise and had no objections 
to either accelerated or delayed

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initiation. 
We study showed no difference in

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90-day. 
Mortality between the 

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Accelerated versus standard 
initiation group, like the 

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previous two studies. 
It also showed that acute 

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paralysis could be avoided in 
almost 40 percent of patients 

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and importantly, they 
highlighted some harm from 

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starting dialysis early. 
There was a higher risk of 

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dialysis dependence at 90 days 
and there were more Adverse 

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Events in the accelerated group.
And overall. 

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There was no obvious benefit 
from starting a cute doll. 

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This earlier. 
So this then brings us to the 

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next question. 
How long can you wait? 

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And this was a question explored
in the icky to trial? 

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Patients with severe, acute 
kidney injury and oliguria or 

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uremia were randomized to 
delayed or very delayed 

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initiation of dialysis. 
The trial showed that again, 

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Dallas is could be avoided if 
you waited for longer, but 

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60-day mortality was higher. 
So together. 

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These trials have given us 
important information and 

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explored the question from 
different angles, but they have 

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still not giving us enough 
information to manage an 

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individual patient at the 
bedside because we still do not 

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know which patient actually 
needs acute paralysis and who 

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can be managed conservatively in
all studies be criteria for 

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either early or late initiation 
was based on serum creatinine or

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severity of acute, kidney 
injury, but in real life at the 

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bedside, there are many other 
Area in fact, acute paralysis is

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a form of organ support, which 
we use to prevent fluid overload

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or normalized metabolic 
derangements or correct fluid 

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overload. 
And so we clearly need more 

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information at the bedside to 
guide us. 

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Dr. Osterman. 
You're in a very experienced 

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clinician and these trials, as 
you've pointed out, have not 

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been fully comprehensive and 
telling us what we need. 

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So what are the most relevant 
parameters that influence your 

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In on who you offer dialysis to 
when you start and when you 

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stopped, my main aim is to give 
treatments to patients who will 

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benefit from them and to avoid 
treatments that may either cause

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more harm than benefits and Q. 
Dallas is no exception. 

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So I view acute paralysis as a 
form of kidney support and I 

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want to start it and offer it to
patients who are in whom King. 

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Any function is not sufficient 
to cope with the complications 

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including metabolic derangements
or fluid overload and I want to 

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start it before the kidneys 
actually fail completely and 

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therefore my Approach consists 
of repeated assessments and 

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evaluation of the trajectories 
and an assessment of the future,

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including the next 12-24 hours 
per day. 

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None of what may happen and 
looking at these Trends and 

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predicting whether patients will
come to harm from the metabolic 

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derangement or the accumulation 
of fluid guides me. 

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So if patients are getting worse
and fluid is building up and 

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metabolic derangements are 
contributing to their condition 

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and acute paralysis is in line 
with the patient's wishes and 

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their overall treatment goal. 
Then I start from Gardeners of 

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the level of creatinine. 
I hope this demonstrates that 

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there are many more factors than
just creating it alone or stage 

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of acute kidney injury, which 
guide and determine our 

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management at the bedside. 
And it became very clear during 

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the recent pandemic, but we may 
need to modify our general 

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approach. 
When dealing with sick patients 

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with acute, kidney injury for 
those just tuning in. 

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You're listening to Katy. 
Your conversation in a prodigy. 

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Our topic today is deciding when
and who should start a cute 

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dialysis from evidence to 
bedside practice. 

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I'm dr. 
Avi Mehta and I'm speaking with 

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dr. 
Molly saw Steven. 

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Dr. Osterman has your experience
with managing patients change 

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during the covid-19 pandemic. 
And if so in what way, I'm 

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afraid during the pandemic, we 
had to change our approach to 

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acute Paralysis on many fronts. 
We like many colleagues facing 

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Unexpected challenges, including
reduced, dialysis capacity, 

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unexpected Supply problems and a
major shortage of nursing staff.

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And the first thing we learned 
was that there are at least two 

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key processes that influence 
timing of acute Paralysis on the

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one hand. 
There is a decision process 

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which focuses on the medical 
decision, but a patient needs 

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dialysis. 
And then there are the logistics

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and they certainly influence and
impact timing. 

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And these challenges forced us 
to adapt our practice. 

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We obviously recruited one 
nurses. 

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We expanded the dialysis 
modalities and use different 

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types of dialysis. 
We even produce dialysis fluid 

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and house to overcome some of 
the challenges. 

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We also changed our approach to 
timing and we carefully assessed

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and reassessed which patient 
needed dialysis urgently. 

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We always ask the question. 
Question, whether it was safe to

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wait, without causing harm, 
whether there are any potential 

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Alternatives. 
And then, lastly, whether we 

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actually had the necessary kid 
and the nurses available to 

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deliver Reno, replace dialysis 
treatment. 

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Overall. 
The aim was to deliver the 

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greatest good for the greatest 
number of patients. 

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I'm very pleased. 
But we've recovered from this 

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period. 
And now, we are back to business

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as usual, which means a more 
personalized approach to timing 

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of Dallas has so, what 
additional information is needed

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currently to help us improve 
care of patients. 

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In the setting, what should 
conditions due to currently 

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manage their patients? 
And are there. 

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Any final messages you'd like to
leave with our listeners? 

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My key messages to emphasize 
that acute, dialysis is a form 

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of support therapy, which should
be considered before kidney 

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function, actually fails 
completely, and the optimal time

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varies from Patient to Patient. 
And to deliver this form of 

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personalized medicine, taking 
into account, all the various 

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aspects from metabolic 
derangement and fluid 

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accumulation to potential. 
Trajectories means that we need 

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more diagnostic tools and 
techniques to come to the right 

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decision. 
And as I already mentioned, it's

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clearly important that we all 
work together. 

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And communicate, well with all 
the relevant people caring for 

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patients including staff and the
team delivering acute paralysis 

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in order to devoid delays. 
After decision, in favor of the 

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queue Dallas has been made. 
I also want to highlight again 

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that acute paralysis is 
delivered and monitored very 

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differently across the world. 
I mean, speaking to colleagues, 

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it's clear that we all use 
different quality metrics and I 

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think It would be nice for us to
agree, some quality indicators 

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so that we can at least have 
similar standards and put 

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Improvement projects in place. 
And then lastly, I would plead 

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have an update of the existing 
Official Guidelines because none

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of them have included the data 
of the recent studies and 

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randomized, controlled trials. 
With that in mind. 

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I was very pleased to hear that 
KD go is making preparation for 

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a State of the que digo 
guideline. 

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That's a great way to round out 
our discussion today. 

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I would like to thank my guests.
Dr. Molly's Osterman for joining

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me. 
Dr. Osterman. 

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It was great. 
Having you on the program. 

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It's been a great honor to 
participate. 

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And I hope today's discussion 
has highlighted some of the 

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ongoing challenges but also the 
enormous advances and progress 

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made in the last 10 years since 
the release of the que digo. 

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Valid in 2012. 
I'm dr. 

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Avi Mehta. 
To access this and other 

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episodes in the series visit que
digo dot org slash podcast. 

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Thanks for listening. 
This episode of que digo 

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conversations in Nephrology was 
provided by KD go and supported 

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by Baxter Healthcare.