In a critically ill kidney, the choice of dialysis may matter far more than the machine

October 14, 2026 online; October 29 journal issue · Multicenter randomized noninferiority trial, stopped early; older online result revisited · Primary source

In critical care, intermittent dialysis and continuous renal-replacement therapy are not interchangeable conveniences. A multicenter trial published October 14 tested whether starting with intermittent hemodialysis was noninferior to continuous therapy for patients with severe acute kidney injury. It is included as a dated clinical anchor, not a newly published October 30 result.

Of 554 randomized patients, 535 were included in the intention-to-treat analysis. Major adverse kidney events at day 90—death, dialysis dependence, or a large creatinine increase—occurred in 78.1% of the intermittent group and 71.6% of the continuous group (adjusted absolute difference 6.28 percentage points, 95% CI −1.22 to 13.79). The prespecified noninferiority criterion was not satisfied. Ninety-day mortality was 63.1% versus 53.5%; the reported hazard ratio for death was 1.30 (95% CI 1.04–1.63). Enrollment stopped early after interim mortality signals.

Early termination, an open-label protocol and the very ill population complicate how broadly the difference should be applied. The composite primary outcome did not show a statistically certain superiority difference, while mortality raised an important safety signal. This is a study for nephrologists and intensivists to examine closely, including treatment timing, hemodynamic tolerance, selection criteria and institutional expertise. The interesting question for The Arising is not technology for its own sake: it is whether the way a therapy is delivered changes survival, recovery and independence.

Clinical reading: Immediate specialty appraisal warranted; do not reduce an ICU modality choice to a general outpatient recommendation.