ICRAKI Trial Stopped Early After Higher Mortality With Intermittent Hemodialysis

Initial treatment with intermittent hemodialysis (IHD) was not shown to be noninferior to continuous renal-replacement therapy (CRRT) for major adverse kidney events in critically ill adults with acute kidney injury (AKI), and it was associated with higher mortality by day 90. The results come from the ICRAKI trial, published online in the New England Journal of Medicine.

The investigators noted that the preferred method of renal-replacement therapy for AKI in critically ill patients remains uncertain. The multicenter, open-label, noninferiority trial randomly assigned critically ill adults with AKI who had indications for renal-replacement therapy to IHD or CRRT as the initial treatment. The French Ministry of Health funded the trial.

The primary outcome was a major adverse kidney event by day 90. This was defined as death, dependence on renal-replacement therapy, or a serum creatinine concentration more than 25% above baseline. Of 554 randomized patients (272 assigned to IHD and 282 to CRRT), 535 were included in the intention-to-treat population (260 and 275, respectively). The primary outcome occurred in 78.1% of the IHD group and 71.6% of the CRRT group (adjusted absolute risk difference, 6.28 percentage points; 95% CI, −1.22 to 13.79).

The trial was stopped early after sequential interim analyses showed a sustained signal of higher mortality with IHD. Death by day 90 occurred in 63.1% of the IHD group and 53.5% of the CRRT group. Kaplan-Meier estimates were 63.3% vs 53.6% (hazard ratio, 1.30; 95% CI, 1.04-1.63). Hypotension was the most common complication potentially related to AKI or renal-replacement therapy, occurring in 68.8% and 66.5% of patients, respectively.

The investigators’ conclusion covers only IHD as the initial treatment approach in critically ill patients with AKI who had indications for renal-replacement therapy. The trial was open label and was stopped early.

Source: Gaudry S, Boubaya M, Louis G, et al. Intermittent or continuous renal-replacement therapy in acute kidney injury. N Engl J Med. Published online October 14, 2026. doi:10.1056/NEJMoa2608397