Effect of early or late initiation of renal replacement therapy on critically illed patients with acute kidney injury: a systematic review and meta-analysis

Wei Shen ,Keyan Wu

doi:10.3760/cma.j.issn.1673-4238.2018.03.003

Abstract

Objective To investigate the impact of renal replacement therapy (RRT) initiation timing on clinical outcomes for patients with acute kidney injury (AKI). Methods We searched all related randomly controlled trials (RCTs) that directly compared earlier and later RRT from PubMed, EMBASE, and Cochrane Library, and extracted the study characteristics and outcomes of all-cause mortality, recovery of renal function, intensive care unit (ICU) and hospital length of stay (LOS). Results Full text of 53 articles was assessed for eligibility. Of these a total of 11 RCTs with 1 773 participants were included. Earlier RRT was not associated with benefits in terms of mortality (relative risk (RR) 0.87, 95% confidence interval (CI) 0.70~1.08, P=0.21). There were also no significant differences in the ICU LOS and recovery of renal functions between the patients who underwent earlier versus later RRT, but early RRT markedly shortened hospital LOS compared to late RRT(standard means difference -6.68 d; 95% CI -12.84 ~ -0.52; P=0.03). In a subgroup analysis based on modality of RRT, earlier RRT was associated with a reduction in the in-hospital mortality among patients who underwent continuous renal replacement therapy (CRRT) (RR=0.80, 95% CI 0.65~0.99). The trials with high or unclear risk of bias for allocation concealment showed benefit of early RRT (RR=0.67, 95% CI 0.49~0.93) while the trials with low risk of bias for allocation concealment showed no difference in the mortality. Conclusion Compared with later RRT, earlier initiation of RRT did not show beneficial impacts on patient outcomes. However, a lower rate of death was observed among the patients who underwent early CRRT. The included paper is heterogeneous and, therefore, potentially subject to bias. Further high-quality RCT studies are warranted. Key words: Acute kidney injury; Renal replacement therapy; Meta-analysis; Timing

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