Abstract
BackgroundThe optimal timing of renal replacement therapy (RRT) initiation is debatable. Many articles in this field enrolled trials not based on acute kidney injury. The safety of the watchful waiting strategy has not been fully discussed, and late RRT initiation criteria vary across studies. The effect of early RRT initiation in the AKI population with high plasma neutrophil gelatinase-associated lipocalin (NGAL) has not been examined yet.MethodsIn accordance with PRISMA guidelines, the PubMed, Embase, and Cochrane databases were systemically searched for randomized controlled trials (RCTs). Trials not conducted in the AKI population were excluded. Data of study characteristics, primary outcome (all-cause mortality), and related secondary outcomes [mechanical ventilation (MV) days, length of hospital stay, RRT days, and length of ICU stay] were extracted. The outcomes were compared between early and late RRT groups by estimating the pooled odds ratio (OR) for binary outcomes and the weighted mean difference for continuous outcomes. Prospective trials were also examined and analyzed using the same method.ResultsNine RCTs with 1938 patients were included. Early RRT did not provide a survival benefit (pooled OR, 0.88; 95% confidence interval [CI] 0.62–1.27). However, the early RRT group had significantly fewer MV days (pooled mean difference, − 3.98 days; 95% CI − 7.81 to − 0.15 days). Subgroup analysis showed that RCTs enrolling the surgical population (P = .001) and the AKI population with high plasma NGAL (P = .031) had favorable outcomes regarding RRT days in the early initiation group. Moreover, 6 of 9 RCTs were selected for examining the safety of the watchful waiting strategy, and no significant differences were found in primary and secondary outcomes between the early and late RRT groups.ConclusionsOverall, early RRT initiation did not provide a survival benefit, but a possible benefit of fewer MV days was detected. Early RRT might also provide the benefit of shorter MV or RRT support in the surgical population and in AKI patients with high plasma NGAL. Depending on the conventional indication for RRT initiation, the watchful waiting strategy is safe on the basis of all primary and secondary outcomes.
Highlights
The optimal timing of renal replacement therapy (RRT) initiation is debatable
Twenty-seven articles were identified to be potentially relevant, and full-text articles were downloaded and assessed for eligibility. Of these 27 articles, 7 were excluded because they were not based on the Acute kidney injury (AKI) population [13,14,15, 29], RRT was not the primary treatment in the late group [30], they had a duplicate cohort with a single reported outcome that could not be used for meta-analysis [31], and no actual event numbers and no information on the baseline characteristics of the early or late RRT initiation groups were available [32] (Additional file 1: Table S5)
Our study mainly focused on Randomized controlled trial (RCT); the results of 10 prospective studies are provided in Additional file 2: Document S2
Summary
The optimal timing of renal replacement therapy (RRT) initiation is debatable Many articles in this field enrolled trials not based on acute kidney injury. The effect of early RRT initiation in the AKI population with high plasma neutrophil gelatinase-associated lipocalin (NGAL) has not been examined yet. According to Bagshaw et al, some severely critically ill patients are unlikely to benefit from early RRT, and several potential drawbacks should be considered, such as higher costs or unnecessary complications from dialysis [74]. Several studies in this field used plasma NGAL as their enrollment criterion.
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