A comparison of early versus late initiation of renal replacement therapy for acute kidney injury in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials

Abstract

BackgroundTo investigate the impact of timing the initiation of renal replacement therapy (RRT) on clinical outcomes in critically ill patients with acute kidney injury (AKI), focusing on the randomized controlled trials (RCTs) in this field.MethodsThe PubMed, EMBASE and Cochrane databases were searched between January 1, 1985, and June 30, 2016, to identify randomized trials that assessed the timing of initiation of RRT in patients with AKI.ResultsNine RCTs, with a total of 1636 patients, were enrolled in this meta-analysis. A pooled analysis of the studies indicated no mortality benefit with “early” RRT, with an RR of 0.98 (95% CI 0.78 to 1.23, P = 0.84). There was no significant difference in intensive care unit (ICU) length of stay (LOS) or hospital LOS between the early and late RRT groups for survivors or nonsurvivors. Pooled analysis also demonstrated no significant change in renal function recovery (RR 1.02, 95% CI 0.88 to 1.19, I2 = 59%), RRT dependence (RR 0.76, 95% CI 0.42 to 1.37, I2 = 0%), duration of RRT (Mean difference 1.43, 95% CI -1.75 to 4.61, I2 = 78%), renal recovery time (Mean difference 0.73, 95% CI -2.09 to 3.56, I2 = 70%) or mechanical ventilation time (Mean difference − 0.95, 95% CI -3.54 to 1.64, I2 = 64%) between the early and late RRT groups. We found no significant differences in complications between the groups.ConclusionsOur meta-analysis revealed that the “early” initiation of RRT in critically ill patients did not result in reduced mortality. Pooled analysis of secondary outcomes also showed no significant difference between the early and late RRT groups. More well-designed and large-scale trials are expected to confirm the result of this meta-analysis.Electronic supplementary materialThe online version of this article (doi:10.1186/s12882-017-0667-6) contains supplementary material, which is available to authorized users.

Factors that influenced undergoing renal replacement therapy and survival in children with acute kidney injury

“…Data about optimal timing of RRT is a controversy. In an adult setting there are some reports showing the survival benefits of early RRT while recent meta‐analyses show no effect of early RRT . Two large multi‐centre randomized trials show conflicting results as well .…”

“…In an adult setting there are some reports showing the survival benefits of early RRT 23 while recent meta-analyses show no effect of early RRT. [24][25][26] Two large multi-centre randomized trials show conflicting results as well. 27,28 The data about the timing of RRT in paediatric AKI is scarce.…”

Comparison between watchful waiting strategy and early initiation of renal replacement therapy in the critically ill acute kidney injury population: an updated systematic review and meta-analysis

“…Earlier retrospective and prospective studies revealed the survival benefits of early RRT initiation; however, since the AKIKI and ELAIN trials published in 2016, these survival benefits have become debatable. In recent years, several meta-analyses have been published, most of which investigated prospective or retrospective studies owing to the lack of large-scale randomized controlled trials (RCTs), and in these meta-analyses, a definitive conclusion regarding the optimal time of RRT initiation could not be drawn [5][6][7][8][9][10][11]. Conventional indications (refractory fluid overload, acidemia, hyperkalemia, and uremic complication) for RRT initiation are indisputable over several years.…”

Acute kidney injury: Epidemiology, outcomes, complications, and therapeutic strategies

“…Despite previous studies investigating the relationship between mortality and the timing of RRT initiation, it remained controversial whether early initiation of RRT improved outcomes. In 2016, two RCTs and in 2017 nine systematic reviews and meta‐analyses evaluated the optimal timing of RRT initiation for AKI. A multicenter RCT study, the Artificial Kidney Initiation in Kidney Injury (AKIKI) study, conducted in France, showed that there were no significant differences in mortality between early and late initiation of RRT .…”

“…Early initiation of RRT (defined as KDIGO stage 3 AKI) in the AKIKI study corresponded to the delayed arm in the ELAIN study. Turning to the conclusions of nine meta-analyses,[90][91][92][93][94][95][96][97][98] the AKI patients in the RCTs who underwent early initiation of RRT did not show a lower mortality rate than those with late RRT [90][91][92][93][94]96,98.…”