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

Xiao-Mei Yang, Guo-Wei Tu, Ji-Li Zheng, Bo Shen, Guo-Guang Ma, Guang-Wei Hao, Jian Gao, Zhe Luo, Xiao-Mei Yang, Guo-Wei Tu, Ji-Li Zheng, Bo Shen, Guo-Guang Ma, Guang-Wei Hao, Jian Gao, Zhe Luo

Abstract

Background: To 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.

Methods: The 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.

Results: Nine 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.

Conclusions: Our 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.

Keywords: Acute kidney injury; Renal replacement therapy; Timing.

Conflict of interest statement

Ethics approval and consent to participate

Ethics approval and consent waived. All the data presented in this review is from previously published studies.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Figures

Fig. 1
Fig. 1
Flow chart of literature selection
Fig. 2
Fig. 2
Forest plot for mortality of 9 studies
Fig. 3
Fig. 3
Forest plot for RRT modality
Fig. 4
Fig. 4
Forest plot for study centers
Fig. 5
Fig. 5
Forest plot for ICU Length of stay
Fig. 6
Fig. 6
Forest plot for hospital length of stay
Fig. 7
Fig. 7
Forest plot for renal function recovery
Fig. 8
Fig. 8
Forest plot for renal replacement therapy dependence
Fig. 9
Fig. 9
Forest plot for duration of renal replacement therapy
Fig. 10
Fig. 10
Forest plot for renal recovery time
Fig. 11
Fig. 11
Forest plot for mechanical ventilation time
Fig. 12
Fig. 12
a Risk of bias summary: review authors’ judgments about each risk of bias item for each included study. b Risk of bias graph: review authors’ judgments about each risk of bias item presented as percentages across all included studies
Fig. 13
Fig. 13
Assessment of publication bias using a funnel plot

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