‘Early’ and ‘late’ timing for renal replacement therapy in acute kidney injury after cardiac surgery: a prospective, interventional, controlled, single-centre trial

Crescenzi, Giuseppe; Torracca, Lucia; Pierri, Michele D.; Rosica, Concetta; Münch, Christopher; Capestro, Filippo

doi:10.1093/icvts/ivv025

Cited by 19 publications

(11 citation statements)

References 23 publications

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“…Fifteen trials [17–20, 23–33] with a total of 1479 patients (771 patients receiving early RRT versus 708 patients receiving late RRT) ultimately met our criteria (Table 1); these included five RCTs [17, 18, 23, 25, 33], one prospective cohort study [29] and nine retrospective cohort studies [19, 20, 24, 26–28, 30–32]. The characteristics and methodological quality of all the included studies are shown in Table 1 and the outcomes in patients with AKI after cardiac surgery are shown in Table 2.…”

Section: Resultsmentioning

confidence: 99%

Early versus late initiation of renal replacement therapy impacts mortality in patients with acute kidney injury post cardiac surgery: a meta-analysis

Zou

Hong

2017

Crit Care

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BackgroundAcute kidney injury (AKI) is a common clinical complication of cardiac surgery and increases mortality and hospitalization. We aimed to explore and perform an updated meta-analysis of qualitative and quantitative evaluations of the relationship between early renal replacement therapy (RRT) and mortality.MethodsWe searched the Chinese Biomedical Database, the Cochrane Library, EMBASE, Global Health, MEDLINE and PubMed.ResultsFifteen studies (five randomized controlled trials (RCTs), one prospective cohort and nine retrospective cohorts) including 1479 patients were identified for detailed evaluation. The meta-analysis suggested that early RRT initiation reduced 28-day mortality (odds ratio (OR) 0.36; 95% confidence interval (CI) 0.23 to 0.57; I 2 60%), and shortened intensive care unit (ICU) length of stay (LOS) (mean difference (MD) -2.50; 95% CI -3.53 to -1.47; I 2 88%) and hospital LOS (MD -0.69; 95% CI -1.13 to -0.25; I 2 88%), and also reduced the duration of RRT (MD -1.18; 95% CI -2.26 to -0.11; I 2 69%), especially when RRT was initiated early within 12 hours (OR 0.23; 95% CI 0.08 to 0.63; I 2 73%) and within 24 hours (OR 0.52; 95% CI 0.28 to 0.95; I 2 58%) in patients with AKI after cardiac surgery.ConclusionsEarly RRT initiation decreased 28-day mortality, especially when it was started within 24 hours after cardiac surgery in patients with AKI.

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Section: Resultsmentioning

confidence: 99%

Early versus late initiation of renal replacement therapy impacts mortality in patients with acute kidney injury post cardiac surgery: a meta-analysis

Zou

Hong

2017

Crit Care

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“…Some other studies showed the association between increased prevalance of arrythmias of patients with ARF and acute coronary syndromes [24]. In our study, despite atrial fi brillation, ventricular fi brillation, ventricular tachycardia and cardioversion rates were similar in both groups but signifi cant hours follow-up of urine output less than 0.5 mL/kg/hour [26].…”

Section: Post Operative Outcomessupporting

confidence: 60%

Acute on Chronic Renal Failure has Worse Postoperative Outcomes than End-Stage Renal Disease Following Cardiac Surgery

Durgun¹

2017

Int J Vasc Surg Med

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Background: Renal failure is a systemic disorder and has destructive effects among all organs including cardiovascular system. The development of postoperative acute kidney injury has been recognized as one of the strongest risk factor for mortality in patients undergoing cardiac surgery. Aim/Objective: To investigate postoperative course of acute on chronic renal failure after cardiac surgery and defi ne perioperativerisk factors for predicting postoperative acute renal failure (ARF) development. Materials and Methods: From January 2006 to December 2014, data of 3038 patients undergone cardiac surgery was retrospectively reviewed. Data of 42 chronic renal failure (CRF) patients who undergone dialysis at early postoperative period (≤30 days after cardiac surgery) were selected and evaluated. Group 1 (n=18) was consisted of patients who have preoperative dialysis dependent CRF and undergone dialysis after cardiac surgery, while Group 2 (n=24) was consisted of patients who have preoperative dialysis nondependent CRF and undergone dialysis after cardiac surgery. Preoperative clinical characteristics and demographics, operational data of patients as well as postoperative outcomes of patient groups were analyzed, hereby a comparison of two groups was performed. Results: There were not statistically difference between groups for neuropsychiatriccomplications, wound infectious complications, septiccomplications, reexploration, duration of ventilation, cardioversion, intraaortic balloon pump support, pleural effusion, pericardial effusion and total drainage amounts. Positive inotropic necessity, signifi cant electrocardiographicchanges, reintubation necessity and transfusion amounts were statistically higher in Group 2. Patients in Group 2 had a signifi cant longer intensive care unit (ICU) stay (mean length of ICU stay was 4 days in Group 1, while 6 days in Group 2, p = 0.01) and total hospital stay (mean length of total hospital stay was 9 days in Group 1, while 15 days in Group 2, p = 0.006). Thirty-day mortality rate was statistically higher in Group 2 (p = 0.044). Conclusion: End stage renal failure is one of the worst preoperative risk factor for cardiac surgery but postoperative ARF development results with worst outcomes even patients had preoperative dialysis non-dependent CRF. So preoperative estimated glomerular fi ltration rate should be calculated to estimate ARF development risk, instead of evaluating with only serum creatinine.

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“…An argument has been made by Ronco et al [17] that this study, along with other recent observational studies [21,23] supports a conclusion that, while early initiation may or may not be beneficial, avoiding or delaying it is associated with increased mortality. We do not agree that this has been clearly established given that recent studies do not consistently report either that delaying or avoiding RRT is harmful, or that earlier initiation is harmless [30][31][32][33][34][35][36] . In particular, multiple, observational studies published in the last 5 years suggest that delaying or avoiding RRT may be beneficial [31,32,34,35] .…”

Section: Insufficient Evidence To Support Ever Earlier Rrtmentioning

confidence: 87%

“…While consensus has been established that RRT should be initiated for 'conventional', potentially lifethreatening indications, the threshold for starting has been lowered such that many patients begin RRT preemptively. Despite this change in practice, there was insufficient evidence to support it: multiple observational studies have suggested decreased mortality with 'earlier' RRT [11,[21][22][23], but many others have suggested that there is no effect [33,36] or that a conservative strategy is superior [30,32,34,35] . In addition, 3 underpowered RCTs have been conducted and none of them have shown significantly improved outcomes with relatively earlier RRT initiation [20,37,38] .…”

Section: Discussionmentioning

confidence: 99%

Progressively Earlier Initiation of Renal Replacement Therapy for Acute Kidney Injury Is Unwarranted and Potentially Harmful

Clark

Hiremath²

2016

Blood Purif

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Background: The optimal timing of renal replacement therapy (RRT) initiation for acute kidney injury (AKI) is unknown. There is debate as to whether starting RRT earlier for AKI is superior to starting it only after ‘conventional', life-threatening indications are present. Summary: In recent years, there has been an ongoing trend in clinical practice to initiate RRT for AKI long before indications appear. Observational studies show many patients now begin RRT for AKI in the absence of ‘conventional' indications. While this shift may have been prompted by observational studies suggesting improved outcomes with earlier RRT, there was not sufficient justification for a change in clinical practice: many recent, observational studies suggest that early RRT may not beneficial or may be even harmful. Moreover, none of 3 underpowered RCTs reported to date found ‘early' RRT initiation beneficial. Lowering the threshold for RRT initiation inevitably leads to more patients receiving unnecessary treatment and this is a matter of concern, considering the fact that complications are potentially fatal and RRT is very costly. While we await definitive studies, calls to shift clinical practice back toward the initiation of RRT for ‘conventional', life‐threatening indications only, should be heeded. Key Messages: ‘Earlier' initiation of RRT for AKI is already occurring in clinical practice but is not justified on the basis of the studies to date. Lowering the threshold for initiation leads to more patients receiving unnecessary RRT. RRT has potentially fatal complications and is expensive. While we await definitive trials, RRT should be started only after ‘conventional', life-threatening indications occur and not earlier.

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‘Early’ and ‘late’ timing for renal replacement therapy in acute kidney injury after cardiac surgery: a prospective, interventional, controlled, single-centre trial

Abstract: This trial is registered in the clinicaltrial.gov registry: NCT01961999.

Cited by 19 publications

References 23 publications

Early versus late initiation of renal replacement therapy impacts mortality in patients with acute kidney injury post cardiac surgery: a meta-analysis

Early versus late initiation of renal replacement therapy impacts mortality in patients with acute kidney injury post cardiac surgery: a meta-analysis

Acute on Chronic Renal Failure has Worse Postoperative Outcomes than End-Stage Renal Disease Following Cardiac Surgery

Progressively Earlier Initiation of Renal Replacement Therapy for Acute Kidney Injury Is Unwarranted and Potentially Harmful

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