Effects of early dialysis on the outcomes of critically ill patients with acute kidney injury: a systematic review and meta-analysis of randomized controlled trials

Wei-Ting Lin,Chih-Cheng Lai,Shen-Peng Chang,Jian-Jhong Wang

doi:10.1038/s41598-019-54777-9

Abstract

The appropriate timing for initiating renal replacement therapy (RRT) in critically ill patients with acute kidney injury (AKI) remains unknown. This meta-analysis aims to assess the efficacy of early initiation of RRT in critically ill patients with AKI. The Pubmed, Embase and Cochrane databases were searched up to August 13, 2019. Only randomized controlled trials (RCTs) comparing the effects of early and late RRT on AKI patients were included. The primary outcome was 28-day mortality. Eleven RCTs including 1131 and 1111 AKI patients assigned to early and late RRT strategies, respectively, were enrolled in this meta-analysis. The pooled 28-day mortality was 38.1% (431/1131) and 40.7% (453/1111) in the patients assigned to early and late RRT, respectively, with no significant difference between groups (risk ratio (RR), 0.95; 95% CI, 0.78–1.15, I2 = 63%). No significant difference was found between groups in terms of RRT dependence in survivors on day 28 (RR, 0.90; 95% CI, 0.67–1.25, I2 = 0%), and recovery of renal function (RR, 1.03; 95% CI, 0.89–1.19, I2 = 56%). The early RRT group had higher risks of catheter-related infection (RR, 1.7, 95% CI, 1.01–2.97, I2 = 0%) and hypophosphatemia (RR, 2.5, 95% CI, 1.25–4.99, I2 = 77%) than the late RRT group. In conclusion, an early RRT strategy does not improve survival, RRT dependence, or renal function recovery in critically ill patients with AKI in comparison with a late RRT strategy. However, clinicians should be vigilant because early RRT can carry higher risks of catheter-related infection and hypophosphatemia during dialysis than late RRT.

Highlights

The appropriate timing for initiating renal replacement therapy (RRT) in critically ill patients with acute kidney injury (AKI) remains unknown
In 2018, one large RCT24 focused on patients with septic shock and severe AKI in the IDEAL-ICU trial found no significant difference in 90-day mortality between patients with early and delayed initiation of RRT
Their findings were consistent with those in another multicenter randomized controlled trials (RCTs) by the AKIKI study group[22], but were contrary to the findings of a recent single-center RCT in the ELAIN trial[23]. All of these findings indicate uncertainty about the usefulness of early RRT in critically ill patients. This issue had been discussed in one meta-analyses[25] recently, we aimed to conduct an updated systematic review and meta-analysis of RCTs to assess the efficacy of early initiation of RRT in critically ill AKI patients

Summary

Introduction

The appropriate timing for initiating renal replacement therapy (RRT) in critically ill patients with acute kidney injury (AKI) remains unknown. RRT is usually initiated for acute management of life-threatening complications of AKI such as severe hyperkalemia, pulmonary edema, refractory metabolic acidosis, uremic pericarditis, and uremic encephalopathy[9] Beyond these indications the appropriate timing for initiating RRT in critically ill patients is unknown. In 2018, one large RCT24 focused on patients with septic shock and severe AKI in the IDEAL-ICU trial found no significant difference in 90-day mortality between patients with early and delayed initiation of RRT Their findings were consistent with those in another multicenter RCT by the AKIKI study group[22], but were contrary to the findings of a recent single-center RCT in the ELAIN trial[23]. This issue had been discussed in one meta-analyses[25] recently, we aimed to conduct an updated systematic review and meta-analysis of RCTs to assess the efficacy of early initiation of RRT in critically ill AKI patients

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Conclusion