{"id":31968,"date":"2026-10-24T04:22:00","date_gmt":"2026-10-23T20:22:00","guid":{"rendered":"https:\/\/csccm.org.cn\/?p=31968"},"modified":"2026-10-24T12:41:42","modified_gmt":"2026-10-24T04:41:42","slug":"nejm%e5%8f%91%e8%a1%a8%e8%bf%b0%e8%af%84%ef%bc%9a%e6%8c%81%e7%bb%ad%e6%8a%91%e6%88%96%e9%97%b4%e6%96%ad%e8%82%be%e8%84%8f%e6%9b%bf%e4%bb%a3%e6%b2%bb%e7%96%97%ef%bc%9a%e9%97%ae%e9%a2%98%e6%98%af","status":"publish","type":"post","link":"https:\/\/csccm.org.cn\/?p=31968","title":{"rendered":"[NEJM\u53d1\u8868\u8ff0\u8bc4]\uff1a\u6301\u7eed\u6291\u6216\u95f4\u65ad\u80be\u810f\u66ff\u4ee3\u6cbb\u7597\uff1a\u95ee\u9898\u662f\u4ec0\u4e48\uff1f"},"content":{"rendered":"\n

EDITORIAL<\/a><\/p>\n\n\n\n

Continuous or Intermittent Renal-Replacement Therapy \u2014 What Is the Question?<\/h1>\n\n\n\n

Paul M.\u00a0Palevsky<\/h3>\n\n\n\n

N Engl J Med Published\u00a0October 14, 2026<\/h3>\n\n\n\n

DOI: 10.1056\/NEJMe2612910<\/h3>\n\n\n\n

Acute kidney injury is a common complication in critically ill patients and is associated with substantial morbidity and mortality. In the absence of effective pharmacotherapy, care is primarily supportive, with reliance on renal-replacement therapy until kidney function recovers. Although more than eight decades have passed since Willem Kolff performed the first successful dialysis treatment and brought a patient with advanced acute kidney injury back from the brink of death, the optimal management of renal-replacement therapy remains uncertain, and mortality still exceeds 50%. Over the course of these decades, the available therapies have proliferated; they currently range from conventional intermittent hemodialysis, which is delivered for 3 to 6 hours daily or every other day, to various continuous therapies \u2014 hemodialysis, hemofiltration, and hemodiafiltration \u2014 which are delivered, as the term \u201ccontinuous\u201d implies, around the clock.1,2<\/a><\/sup><\/p>\n\n\n\n

Each of these therapies has advantages and drawbacks. Intermittent hemodialysis provides more rapid correction of fluid and electrolyte disturbances and more rapid removal of accumulated toxins than continuous therapies, and a single machine may be used successively to treat multiple patients. The rapidity of treatment, however, can result in rapid fluid and electrolyte shifts that may contribute to hemodynamic instability. Lower solute clearances and slower volume removal during continuous renal-replacement therapy theoretically cause less hemodynamic stress. The question of which approach is better has been the subject of passionate debate. Performing randomized trials to rigorously compare intermittent hemodialysis with continuous renal-replacement therapy has been challenging, because clinicians differ on the definition of equipoise and on the question of which patients are candidates for randomization. Clinical practice guidelines suggest the use of continuous renal-replacement therapy, rather than standard intermittent renal-replacement therapy, for patients with hemodynamic instability, particularly those receiving high-dose vasopressor support.3<\/a><\/sup><\/p>\n\n\n\n

Despite the challenges, multiple small to moderately sized trials have been completed. A systematic review and meta-analysis of seven trials showed no evidence of a difference in survival with continuous renal-replacement therapy as compared with intermittent hemodialysis (relative risk, 1.00; 95% confidence interval [CI], 0.92 to 1.09).4<\/a><\/sup> More recently, debate has focused on the recovery of kidney function, with some observational analyses suggesting that intermittent therapy impairs such recovery.5,6<\/a><\/sup><\/p>\n\n\n\n

Gaudry and colleagues7<\/a><\/sup> now report in the Journal<\/em> the results of the ICRAKI (Intermittent Hemodialysis versus Continuous Renal-Replacement Therapy for Severe Acute Kidney Injury) trial, which assessed whether the use of intermittent hemodialysis as the initial therapy is noninferior to the use of continuous renal-replacement therapy in critically ill patients with severe acute kidney injury. The assigned therapy was maintained for at least 4 consecutive days, unless kidney function recovered; after the fourth day, clinicians were free to switch to the other treatment method on the basis of usual clinical practice. The primary outcome was a composite of death, dependence on renal-replacement therapy, or a decline in kidney function from baseline (as indicated by a serum creatinine concentration more than 25% above the baseline value), assessed at day 90.<\/p>\n\n\n\n

The planned trial enrollment was 1000 patients; however, the trial was terminated after only 554 patients had undergone randomization, owing to higher 28-day mortality in the intermittent group than in the continuous group. A primary-outcome event occurred in 78.1% of the patients initially treated with intermittent hemodialysis, as compared with 71.6% of those assigned to undergo continuous renal-replacement therapy, results that met neither the prespecified noninferiority margin for intermittent hemodialysis nor the criterion for superiority of continuous renal-replacement therapy. Death by day 90 occurred in 63.1% of the patients in the intermittent group, as compared with 53.5% of those in the continuous group; Kaplan-Meier mortality estimates at day 90 were 63.3% and 53.6%, respectively (hazard ratio, 1.30; 95% CI, 1.04 to 1.63).<\/p>\n\n\n\n

Because of early termination, the trial was underpowered, which limits the interpretation of the primary outcome. The difference in mortality between the two trial groups further limits our ability to assess whether the initial method of renal-replacement therapy affects kidney recovery. The higher mortality in the intermittent group than in the continuous group was unexpected, particularly in light of previous studies that showed no difference in survival. The reason for the higher mortality is uncertain; however, the overall observed mortality in the ICRAKI trial was higher than that in previous trials and corresponded to that among patients who underwent renal-replacement therapy in the delayed-treatment groups in the AKIKI (Artificial Kidney Initiation in Kidney Injury) and STARRT-AKI (Standard versus Accelerated Initiation of Renal-Replacement Therapy in Acute Kidney Injury) trials, which suggests that adherence to newer criteria for the initiation of renal-replacement therapy may have contributed to differences in the enrolled patient cohort.8,9<\/a><\/sup><\/p>\n\n\n\n

Additional research will be needed to confirm the ICRAKI results. We must also consider whether we are asking the right question. The selection of the method of renal-replacement therapy in the intensive care unit (ICU) is not a random choice. In some health care systems, virtually all renal-replacement therapy in the ICU is provided as continuous renal-replacement therapy, with patients transitioning to intermittent therapy when they are ready to transfer out of the ICU; in other systems where both intermittent and continuous therapy are available, continuous renal-replacement therapy is used in patients with greater hemodynamic instability. In comparing these strategies, the difference does not hinge on the initial method of renal-replacement therapy. There are also other options for renal-replacement therapy, including prolonged intermittent therapies and peritoneal dialysis.1<\/a><\/sup> The real question is not which specific method is superior, but how best to integrate the use of these multiple therapies to improve patient outcomes.<\/p>\n","protected":false},"excerpt":{"rendered":"

EDITORIAL Continuous or Intermittent Renal-Replacement […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"closed","ping_status":"closed","sticky":false,"template":"","format":"standard","meta":[],"categories":[24,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/31968"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=31968"}],"version-history":[{"count":1,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/31968\/revisions"}],"predecessor-version":[{"id":31969,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/31968\/revisions\/31969"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=31968"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=31968"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=31968"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}