Early versus delayed initiation of renal replacement therapy for acute kidney
            injury: an updated systematic review, meta-analysis, meta-regression and trial
            sequential analysis of randomized controlled trials

Moreira, Fábio Tanzillo; Palomba, Henrique; Chaves, Renato Carneiro de Freitas; Bouman, Catherine S. C.; Schultz, Marcus J.; Neto, Ary Serpa

doi:10.5935/0103-507x.20180054

Cited by 15 publications

(8 citation statements)

References 29 publications

Supporting

Mentioning

Contrasting

Unclassified

Order By: Relevance

“…On the contrary, Moreira et al found an increased risk of catheter-related bloodstream infection when renal replacement therapy was initiated early. Moreira FT, et al [10] our study doesn’t confirm this finding.…”

Section: Discussioncontrasting

confidence: 79%

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

2019

View full text Add to dashboard Cite

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.

show abstract

Section: Discussioncontrasting

confidence: 79%

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

2019

View full text Add to dashboard Cite

show abstract

“…However, a considerable proportion of the included studies in these three reviews were non-RCTs, meaning that the data were prone to confounding factors. Another two meta-analyses with TSA of RCTs conducted by Moreira et al and Feng et al failed to establish sufficient and conclusive evidences, because the cumulative Z curve did not cross the conventional boundary, the trial sequential monitoring boundary and the futility boundary, and the required information size was not reached [ 33 , 34 ]. However, in our meta-analysis, the cumulative Z curve crossed the futility boundaries, suggesting the results that early initiation of RRT was not associated with a lower mortality were reliable.…”

Section: Discussionmentioning

confidence: 99%

Timing of renal replacement therapy initiation for acute kidney injury in critically ill patients: a systematic review of randomized clinical trials with meta-analysis and trial sequential analysis

Liu²,

Mao

et al. 2021

Crit Care

View full text Add to dashboard Cite

Background Acute kidney injury (AKI) is a common serious complication in critically ill patients. AKI occurs in up to 50% patients in intensive care unit (ICU), with poor clinical prognosis. Renal replacement therapy (RRT) has been widely used in critically ill patients with AKI. However, in patients without urgent indications such as acute pulmonary edema, severe acidosis, and severe hyperkalemia, the optimal timing of RRT initiation is still under debate. We conducted this systematic review of randomized clinical trials (RCTs) with meta-analysis and trial sequential analysis (TSA) to compare the effects of early RRT initiation versus delayed RRT initiation. Methods We searched databases (PubMed, EMBASE and Cochrane Library) from inception through to July 20, 2020, to identify eligible RCTs. The primary outcome was 28-day mortality. Two authors extracted the data independently. When the I2 values < 25%, we used fixed-effect mode. Otherwise, the random effects model was used as appropriate. TSA was performed to control the risk of random errors and assess whether the results in our meta-analysis were conclusive. Results Eleven studies involving 5086 patients were identified. Two studies included patients with sepsis, one study included patients with shock after cardiac surgery, and eight others included mixed populations. The criteria for the initiation of RRT, the definition of AKI, and RRT modalities existed great variations among the studies. The median time of RRT initiation across studies ranged from 2 to 7.6 h in the early RRT group and 21 to 57 h in the delayed RRT group. The pooled results showed that early initiation of RRT could not decrease 28-day all-cause mortality compared with delayed RRT (RR 1.01; 95% CI 0.94–1.09; P = 0.77; I2 = 0%). TSA result showed that the required information size was 2949. The cumulative Z curve crossed the futility boundary and reached the required information size. In addition, early initiation of RRT could lead to unnecessary RRT exposure in some patients and was associated with a higher incidence of hypotension (RR 1.42; 95% CI 1.23–1.63; P < 0.00001; I2 = 8%) and RRT-associated infection events (RR 1.34; 95% CI 1.01–1.78; P = 0.04; I2 = 0%). Conclusions This meta-analysis suggested that early initiation of RRT was not associated with survival benefit in critically ill patients with AKI. In addition, early initiation of RRT could lead to unnecessary RRT exposure in some patients, resulting in a waste of health resources and a higher incidence of RRT-associated adverse events. Maybe, only critically ill patients with a clear and hard indication, such as severe acidosis, pulmonary edema, and hyperkalemia, could benefit from early initiation of RRT.

show abstract

“…The appropriate time to initiate RRT in a critical care setting has not been defined [20]. Studies on the issues of early versus delayed initiation of RRT show heterogeneous results in a critical care setting [21–23]. In the case of OHCA treated with TTM, studies on early initiation of RRT have not yet been conducted.…”

Section: Discussionmentioning

confidence: 99%

Recovery from acute kidney injury as a potent predictor of survival and good neurological outcome at discharge after out-of-hospital cardiac arrest

Park

Choi

et al. 2019

Crit Care

View full text Add to dashboard Cite

Background Acute kidney injury (AKI) after out-of-hospital cardiac arrest (OHCA) is a well-known predictor for mortality. However, the natural course of AKI including recovery rate after OHCA is uncertain. This study investigated the clinical course of AKI after OHCA and determined whether recovery from AKI impacted the outcomes of OHCA. Methods This retrospective multicentre cohort study included adult OHCA patients treated with targeted temperature management (TTM) between January 2016 and December 2017. AKI was diagnosed using the Kidney Disease: Improving Global Outcomes criteria. The primary outcome was the recovery rate after AKI and its association with survival and good neurological outcome at discharge. Results A total of 3697 OHCA patients from six hospitals were screened and 275 were finally included. AKI developed in 175/275 (64%) patients and 69/175 (39%) patients recovered from AKI. In most cases, AKI developed within three days of return of spontaneous circulation [155/175 (89%), median time to AKI development 1 (1–2) day] and patients recovered within seven days of return of spontaneous circulation [59/69 (86%), median time to AKI recovery 3 (2–7) days]. Duration of AKI was significantly longer in the AKI non-recovery group than in the AKI recovery group [5 (2–9) vs. 1 (1–5) days; P < 0.001]. Most patients were diagnosed with AKI stage 1 initially [120/175 (69%)]. However, the number of stage 3 AKI patients increased from 30/175 (17%) to 77/175 (44%) after the initial diagnosis of AKI. The rate of survival discharge was significantly higher in the AKI recovery group than in the AKI non-recovery group [45/69 (65%) vs. 17/106 (16%); P < 0.001]. Recovery from AKI was a potent predictor of survival and good neurological outcome at discharge in the multivariate analysis (adjusted odds ratio, 8.308; 95% confidence interval, 3.120–22.123; P < 0.001 and adjusted odds ratio, 36.822; 95% confidence interval, 4.097–330.926; P = 0.001). Conclusions In our cohort of adult OHCA patients treated with TTM ( n = 275), the recovery rate from AKI after OHCA was 39%, and recovery from AKI was a potent predictor of survival and good neurological outcome at discharge. Electronic supplementary material The online version of this article (10.1186/s13054-019-2535-1) contains supplementary material, which is available to authorized users.

show abstract

Early versus delayed initiation of renal replacement therapy for acute kidney injury: an updated systematic review, meta-analysis, meta-regression and trial sequential analysis of randomized controlled trials

Cited by 15 publications

References 29 publications

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

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

Timing of renal replacement therapy initiation for acute kidney injury in critically ill patients: a systematic review of randomized clinical trials with meta-analysis and trial sequential analysis

Recovery from acute kidney injury as a potent predictor of survival and good neurological outcome at discharge after out-of-hospital cardiac arrest

Contact Info

Product

Resources

About