A large French randomized trial published in the New England Journal of Medicine has found that, for critically ill adults with acute kidney injury who need dialysis, starting with intermittent hemodialysis rather than continuous renal-replacement therapy (CRRT) was associated with higher mortality at 90 days. The ICRAKI trial was stopped early after interim analyses showed a sustained mortality signal, and it failed to show that intermittent dialysis was “noninferior” to the continuous approach.
The question of which dialysis method works best for acute kidney injury in the intensive care unit (ICU) has been debated for decades. Earlier, smaller trials mostly found no survival difference, and many hospitals use both methods depending on equipment, staffing and patient stability. This study is one of the largest randomized tests of the choice to date.
Acute Kidney Injury Dialysis Study: Key Findings at a Glance
Verified facts from the published abstract (Gaudry et al., NEJM, published online Oct. 14, 2026):
| Outcome by day 90 | Intermittent hemodialysis (n=260) | Continuous RRT (n=275) |
|---|---|---|
| Major adverse kidney event (primary outcome) | 203 patients (78.1%) | 197 patients (71.6%) |
| Death | 164 patients (63.1%) | 147 patients (53.5%) |
| Kaplan–Meier mortality estimate | 63.3% | 53.6% |
| Hypotension (most common complication) | 179 patients (68.8%) | 183 patients (66.5%) |
- Primary outcome: The adjusted absolute risk difference in major adverse kidney events was 6.28 percentage points (95% CI, −1.22 to 13.79). Intermittent dialysis was not shown to be noninferior.
- Mortality: The hazard ratio for death with intermittent hemodialysis was 1.30 (95% CI, 1.04 to 1.63).
- Early stop: The trial was halted after sequential interim analyses showed a sustained signal of higher mortality in the intermittent group.
- Funding: French Ministry of Health (Programme Hospitalier de Recherche Clinique 2021). ClinicalTrials.gov number NCT06032884.
How the ICRAKI Trial Was Designed
ICRAKI was a multicenter, open-label, noninferiority trial run in intensive care units across France. The lead author is Stéphane Gaudry, M.D., Ph.D., of Hôpital Avicenne (AP-HP) in Bobigny, France, writing for the ICRAKI Trial Group.
- Who was enrolled: Critically ill adults with acute kidney injury who already had a clinical indication for renal-replacement therapy.
- Randomization: 554 patients were randomly assigned — 272 to intermittent hemodialysis and 282 to continuous renal-replacement therapy as the initial treatment. The intention-to-treat analysis included 535 patients (260 and 275).
- Primary outcome: A “major adverse kidney event” by day 90, defined as death, ongoing dependence on dialysis, or a serum creatinine level more than 25% above baseline.
What is the difference between the two dialysis methods?
- Intermittent hemodialysis runs in sessions lasting a few hours. It clears waste and corrects fluid and electrolyte problems quickly.
- Continuous renal-replacement therapy runs around the clock at a slower rate. It removes fluid more gradually and is generally considered gentler on blood pressure and circulation.
Who Is Affected
Acute kidney injury is common in ICUs, particularly among patients with sepsis, shock, major surgery or severe respiratory failure. The findings are most directly relevant to:
- Critically ill patients and their families, who may be asked about dialysis decisions in the ICU.
- Intensivists and nephrologists, who choose the initial dialysis method.
- Hospitals and health systems, since CRRT requires dedicated machines, consumables and continuous nursing time, while intermittent dialysis can share equipment and staff with routine dialysis services.
This study does not address chronic dialysis for people with long-term kidney failure, which is a different setting. For background on kidney and cardiovascular risk factors, see our explainer on blood pressure readings and what the numbers mean.
Implications for ICU Care
Analysis: If the result holds up, it strengthens the case for continuous therapy as the default first approach for many critically ill patients who need dialysis — not only those who are visibly unstable. That could have practical consequences for ICU staffing, equipment budgets and training, particularly in hospitals that currently rely mainly on intermittent dialysis.
What the trial does not show: The published conclusion is limited to the initial treatment choice. It does not establish which method is best later in a patient’s ICU stay, and it does not prove a specific mechanism for the mortality difference.
Limitations and Open Questions
- Stopped early: Trials halted early for a safety signal can overestimate the size of an effect. ICRAKI analyzed 535 patients, fewer than originally planned.
- Open-label design: Clinicians knew which therapy each patient received, which can influence other care decisions.
- Primary outcome not conclusive on its own: The confidence interval for the primary outcome (−1.22 to 13.79 percentage points) crosses zero; the trial’s key finding is that noninferiority was not shown, with mortality as a notable secondary result.
- Single-country setting: All sites were in France, so results may not translate directly to health systems with different ICU practices.
- Prior evidence differs: Earlier randomized trials generally found no survival difference between the two methods, so further studies and meta-analyses are likely to weigh in.
What Happens Next
Developing: Professional societies and guideline committees typically review major trials like this before changing recommendations; no guideline changes have been announced. The full paper, protocol and supplementary appendix are available on NEJM.org. Patients or families with questions about dialysis in the ICU should speak directly with the treating care team.
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Sources
- Gaudry S, et al., for the ICRAKI Trial Group. “Intermittent or Continuous Renal-Replacement Therapy in Acute Kidney Injury.” New England Journal of Medicine, published online Oct. 14, 2026. DOI: 10.1056/NEJMoa2608397.
- ClinicalTrials.gov: ICRAKI, NCT06032884.
- Healio: Mortality risks higher with intermittent vs. continuous renal replacement therapy in AKI (Oct. 15, 2026).
This article is for general information only and is not medical advice.
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