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Earlier versus later initiation of renal replacement therapy among critically ill
patients with acute kidney injury: a systematic review and meta-analysis of
randomized controlled trials
#MMPMID28382597
Lai TS
; Shiao CC
; Wang JJ
; Huang CT
; Wu PC
; Chueh E
; Chueh SJ
; Kashani K
; Wu VC
Ann Intensive Care
2017[Dec]; 7
(1
): 38
PMID28382597
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BACKGROUND: Although the optimal timing of initiation of renal replacement
therapy (RRT) in critically ill patients with acute kidney injury has been
extensively studied in the past, it is still unclear. METHODS: In this systematic
review, we searched all related randomized controlled trials (RCTs) that directly
compared earlier and later RRT published prior to June 25, 2016, from PubMed,
MEDLINE, and EMBASE. We extracted the study characteristics and outcomes of
all-cause mortality, RRT dependence, and intensive care unit (ICU) and hospital
length of stay (LOS). RESULTS: We identified 51 published relevant studies from
13,468 screened abstracts. Nine RCTs with 1627 participants were included in this
meta-analysis. Earlier RRT was not associated with benefits in terms of mortality
[relative risk (RR) 0.88, 95% confidence interval (CI) 0.68-1.14, p = 0.33] and
RRT dependence (RR 0.81, 95% CI 0.46-1.42, p = 0.46). There were also no
significant differences in the ICU and hospital LOS between patients who
underwent earlier versus later RRT [standard means difference -0.08 (95% CI -0.26
to 0.09) and -0.11 (95% CI -0.37 to 0.16) day, respectively]. In subgroup
analysis, earlier RRT was associated with a reduction in the in-hospital
mortality among surgical patients (RR 0.78, 95% CI 0.64-0.96) and patients who
underwent continuous renal replacement therapy (CRRT) (RR 0.80, 95% CI
0.67-0.96). CONCLUSIONS: Compared with later RRT, earlier initiation of RRT did
not show beneficial impacts on patient outcomes. However, a lower rate of death
was observed among surgical patients and in those who underwent CRRT. The
included literature is highly heterogeneous and, therefore, potentially subject
to bias. Further high-quality RCT studies are warranted.
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