Initiation time of renal replacement therapy on patients with acute kidney injury: A systematic review and meta‐analysis of 8179 participants

Abstract

ABSTRACT:The early initiation of renal replacement therapy has been recommended for patients with acute renal failure by some studies, but its effects on mortality and renal recovery are unknown. We conducted an updated meta-analysis to provide quantitative evaluations of the association between the early initiation of renal replacement therapy and mortality for patients with acute kidney injury. After applying inclusion/exclusion criteria, 51 studies, including 10 randomized controlled trials, with a total of 8179 patients were analyzed. Analysis of the included trials showed that patients receiving early renal replacement therapy had a 25% reduction in all-cause mortality compared to those receiving late renal replacement therapy (risk ratio [RR] 0.75, 95% CI [0.69, 0.82]). We also noted a 30% increase in renal recovery (RR 1.30, 95% CI [1.07, 1.56]), a reduction in hospitalization of 5.84 days (mean difference [MD], 95% CI [-10.27, -1.41]) and a reduction in the duration of mechanical ventilation of 2.33 days (MD, 95% CI [-3.40, -1.26]) in patients assigned to early renal replacement therapy. The early initiation of renal replacement therapy was associated with a decreased risk of all-cause mortality compared with the late initiation of RRT in patients with acute kidney injury. These findings should be interpreted with caution given the heterogeneity between studies. Further studies are needed to identify the causes of mortality and to assess whether mortality differs by dialysis dose.

Timing of renal replacement therapy in critically ill patients with acute kidney injury

“…The results of both studies are obviously not comparable due to high discrepancies in study design, and they both do not arrive at definitive conclusions. However, these findings together with the results of a recently performed meta-analysis (15) suggest that "early" initiation of renal replacement therapy might improve the survival of critically ill patients with acute kidney injury. Future multicenter randomized controlled studies are requested not to focus only on mortality but also on renal recovery and progression of acute kidney injury to chronic kidney disease.…”

“…The only available treatment option of severe acute kidney injury in critically ill patients is renal replacement therapy (1,2). However, a number of issues affecting the optimal use of this primarily supportive technique still remain unresolved (3).…”

“…The most important question now increasingly being asked is at what point and at which stage to initiate renal replacement therapy in critically ill patients with evolving acute kidney injury. Up to now, the KDIGO guidelines recommend to initiate renal replacement therapy emergently in case of the development of life-threatening complications such as hyperkalemia or severe fluid overload or greater imbalances or disruptions in homeostasis (2). The guidelines do not contain unequivocal instructions how to proceed when a progressive deterioration of kidney function coincides with any serious worsening of the patients' clinical condition, and leave the final decision for renal replacement therapy under these circumstances to the attending physician (2).…”

“…Up to now, the KDIGO guidelines recommend to initiate renal replacement therapy emergently in case of the development of life-threatening complications such as hyperkalemia or severe fluid overload or greater imbalances or disruptions in homeostasis (2). The guidelines do not contain unequivocal instructions how to proceed when a progressive deterioration of kidney function coincides with any serious worsening of the patients' clinical condition, and leave the final decision for renal replacement therapy under these circumstances to the attending physician (2). The clear ambiguities of the KDIGO guidelines could erroneously be taken as a basis to delay renal replacement therapy in an attempt to give more time for spontaneous recovery of renal function.…”

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 .…”