Early initiation of renal replacement therapy in critically ill patients: a meta-analysis of randomized clinical trials

Abstract

Background Acute kidney injury (AKI) is strongly associated with high morbidity and mortality of critically ill patients. In the last years several different biological markers with higher sensitivity and specificity for the occurrence of renal impairment have been developed in order to promptly recognize and treat AKI. Nonetheless, their potential role in improving patients’ outcome remains unclear since the effectiveness of an “earlier” initiation of renal replacement therapy (RRT) is still debated. Since one large, high-quality randomized clinical trial has been recently pubblished, we decided to perform a meta-analysis of all the RCTs ever performed on “earlier” initiation of RRT versus standard RRT in critically ill patients with AKI to evaluate its effect on major outcomes. Methods Pertinent studies were independently searched in BioMedCentral, PubMed, Embase, and Cochrane Central Register of clinical trials. The following inclusion criteria were used: random allocation to treatment (“earlier” initiation of RRT versus later/standard initiation); critically ill patients. Results Ten trials randomizing 2214 patients, 1073 to earlier initiation of RRT and 1141 to later initiation were included. No difference in mortality (43.3% (465 of 1073) for those receiving early RRT and 40.8% (466 of 1141) for controls, p = 0.97) and survival without dependence on RRT (3.6% (34 of 931) for those receiving early RRT and 4.2% (40 of 939) for controls, p = 0.51) were observed in the overall population. On the contrary, early initiation of RRT was associated with a significant reduction in hospital length of stay. No differences in occurrence of adverse events were observed. Conclusions Our study suggests that early initiation of RRT in critically ill patients with AKI does not provide a clinically relevant advantage when compared with standard/late initiation. Electronic supplementary material The online version of this article (10.1186/s12871-019-0733-7) contains supplementary material, which is available to authorized users.

Effects of early dialysis on the outcomes of critically ill patients with acute kidney injury: a systematic review and meta-analysis of randomized controlled trials

“…All these findings are consistent with previous meta-analyses 25,[28][29][30] , and indicate that early RRT does not provide additional survival benefits for AKI patients compared with late RRT. In addition to mortality, Pasin et al 25 ever showed that early RRT was associated with a significant reduction in length of hospital stay. However, the positive impact of early RRT on the length of hospital stay still need further confirmation in the high-quality studies.…”

Early versus late initiation of renal replacement therapy for acute kidney injury in critically ill patients: A systematic review and meta-analysis

“…After this meta-analysis was submitted for initial review by PLOS ONE, Pasin et al published an additional meta-analysis[26]. Their main conclusion was that early initiation of RRT in critically ill patients with AKI does not provide a clinically relevant advantage when compared with late initiation is like this study.…”

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

“…However, there were also some passive or controversial studies on the effect of early RRT in patients with AKI, such as some review articles that suggested that it was not necessary to perform early RRT for clinicians [12,33,34]. They were opposed to early RRT because it could expose patients to potential risks such as thrombosis, hemorrhage, bacteremia, hypersensitivity to the extracorporeal circuit or antibiotics, clearance of trace elements and intradialytic hypotension, which could lead to added the waste of resources [35,36].…”

“…RRT is known to improve the survival rate of patients with AKI in ICU, because it rectifies metabolic acidosis by removing lactate, regulating unmeasured anions and adjusting levels of phosphate and chloride [10,11]. It is widely consentient that if there are lifethreatening complications for septic patients with AKI, such as hyperkalemia, metabolic acidosis and acute pulmonary edema, RRT should be started immediately [5,[12][13][14][15].…”