ESICM LIVES 2026:, Intermittent vs Continuous Renal Replacement Therapy: New Evidence from the CRAKI Trial Is intermittent haemodialysis equivalent to continuous renal replacement therapy in critically ill patients with acute kidney injury? Prof Stéphane Gaudry presented the results of the CRAKI randomized controlled trial, addressing one of the most important questions in renal support for critically ill patients. Over the past decade, studies such as AKIKI, IDEAL ICU and STARRT AKI have transformed our approach to renal replacement therapy (RRT), supporting a more conservative initiation strategy in patients without urgent indications. However, once RRT becomes necessary, does the modality influence outcomes? The CRAKI trial randomized 535 critically ill patients with AKI requiring RRT to intermittent haemodialysis (IHD, n=260) or continuous renal replacement therapy (CRRT, n=275). The findings challenge the assumption that both modalities provide equivalent outcomes. At day 90, major adverse kidney events occurred in 78.1% of patients receiving IHD compared with 71.6% receiving CRRT. The adjusted absolute risk difference was 6.28 percentage points (95% CI -1.22 to 13.79), exceeding the predefined noninferiority margin of 7.5 percentage points. Consequently, noninferiority of IHD could not be demonstrated. More concerning was the mortality signal. At day 90, mortality reached 63.3% in the IHD group compared with 53.6% in the CRRT group, with a hazard ratio of 1.30 (95% CI 1.04 to 1.63). These findings suggest that the initial RRT modality may influence outcomes beyond solute clearance and fluid removal. From a physiological perspective, CRRT permits gradual fluid and solute management, potentially reducing abrupt haemodynamic disturbances in patients with limited cardiovascular reserve. Nevertheless, physiological plausibility should not be confused with demonstrated mechanisms. The trial does not establish that CRRT is superior for every ICU patient, nor does failure to demonstrate noninferiority automatically prove superiority. Our decision about when to initiate RRT must remain separate from our decision about which modality to use. For critically ill patients with severe AKI requiring renal support, CRAKI provides an important signal favouring CRRT and challenges the routine assumption that intermittent and continuous modalities are interchangeable. Further examination of the complete trial results will be essential before translating these findings into universal recommendations. #ESICM #LIVES2026 #CriticalCare #AcuteKidneyInjury #CRRT #RenalReplacementTherapy #IntensiveCare