A randomized trial testing two dialysis strategies for critically ill patients with acute kidney injury was stopped early after an interim analysis found higher mortality with intermittent hemodialysis. The ICRAKI trial, conducted in French ICUs, compared initial intermittent hemodialysis with continuous renal-replacement therapy. By day 90, 63.1% of patients in the intermittent group had died versus 53.5% in the continuous group, corresponding to a 30% higher relative risk of death (HR 1.30, 95% CI 1.04-1.63).
The trial enrolled 554 of a planned 1,000 patients. Most participants were in the ICU for medical reasons, over 70% were on mechanical ventilation, and common comorbidities included hypertension, diabetes, and chronic kidney disease. The primary endpoint—a major adverse kidney event by day 90—occurred in 78.1% of the intermittent group versus 71.6% of the continuous group. Hypotension was the most common complication in both arms, occurring in about two-thirds of patients.
The researchers described the higher mortality in the intermittent group as "unexpected" based on prior literature and "not readily explained." They noted that earlier trials were conducted before standardized criteria for starting renal-replacement therapy were established, whereas ICRAKI enrolled only patients with documented indications. They also acknowledged that post hoc analyses suggested greater hemodynamic stress with intermittent dialysis, but called these findings hypothesis-generating and not proof of a causal mechanism.
An accompanying editorial by Paul Palevsky argued that the real question is not which method is superior but how best to integrate multiple therapies. He noted that practice guidelines already suggest continuous therapy for hemodynamically unstable patients, and that in many systems patients transition between modalities depending on their condition. The trial does not establish which method is preferable after the first three days, when risk-benefit trade-offs may differ, the study authors said.