Abstract
IntroductionThe objective of this systematic review and meta-analysis was to determine the effect of renal replacement therapy (RRT), delivered as hemofiltration vs. hemodialysis, on clinical outcomes in patients with acute kidney injury (AKI).MethodsMEDLINE, EMBASE and CENTRAL databases and conference abstracts were searched to June 2012 for parallel-group or crossover randomized and quasi-randomized controlled trials (RCTs) evaluating hemofiltration vs. hemodialysis in patients with AKI. Two authors independently selected studies and abstracted data on study quality and outcomes. Additional information was obtained from trial authors. We pooled data using random-effects models.ResultsOf 6,657 citations, 19 RCTs (10 parallel-group and 9 crossover) met inclusion criteria. Sixteen trials used continuous RRT. Study quality was variable. The primary analysis included three parallel-group trials comparing similar doses of hemofiltration and hemodialysis; sensitivity analyses included trials comparing combined hemofiltration-hemodialysis or dissimilar doses. We found no effect of hemofiltration on mortality (risk ratio (RR) 0.96, 95% confidence interval (CI) 0.73 to 1.25, P = 0.76; three trials, n = 121 (primary analysis); RR 1.10, 95% CI 0.88 to 1.38, P = 0.38; eight trials, n = 540 (sensitivity analysis)) or other clinical outcomes (RRT dependence in survivors, vasopressor use, organ dysfunction) compared to hemodialysis. Hemofiltration appeared to shorten time to filter failure (mean difference (MD) -7 hours, 95% CI (-19,+5), P = 0.24; two trials, n = 50 (primary analysis); MD -5 hours, 95% CI (-10, -1), P = 0.01; three trials, n = 113 (including combined hemofiltration-hemodialysis trials comparing similar doses); MD -6 hours, 95% CI (-10, -1), P = 0.02; five trials, n = 383 (sensitivity analysis)). Data primarily from crossover RCTs suggested that hemofiltration increased clearance of medium to larger molecules, including inflammatory cytokines, compared to hemodialysis, although almost no studies measured changes in serum concentrations. Meta-analyses were based on very limited data.ConclusionsData from small RCTs do not suggest beneficial clinical outcomes from hemofiltration, but confidence intervals were wide. Hemofiltration may increase clearance of medium to larger molecules. Larger trials are required to evaluate effects on clinical outcomes.
Highlights
The objective of this systematic review and meta-analysis was to determine the effect of renal replacement therapy (RRT), delivered as hemofiltration vs. hemodialysis, on clinical outcomes in patients with acute kidney injury (AKI)
Study selection Two unblinded reviewers assessed full-text reports and included studies meeting the following criteria: (1) design: either parallel-group or cross-over randomized or quasi-randomized controlled trial, (2) population: adult or post-neonatal pediatric patients with AKI requiring RRT, (3) intervention: hemofiltration compared to hemodialysis, with both modes applied using continuous or intermittent RRT; trials comparing continuous to intermittent RRT were excluded, (4) outcomes: all-cause mortality or other clinically important outcomes for the parallel-group trials; or group-specific filter duration, or clearance or plasma concentration measurements of cleared substances for both parallel-group and crossover trials
In six of the remaining seven parallel-group trials, patients treated with hemofiltration (n = 20 [21], n = 206 [26], n = 96 [27]) or hemodialysis (n = 13 [22], n = 39 [23], n = 60 [29]) were compared to a group treated with hemodiafiltration
Summary
The objective of this systematic review and meta-analysis was to determine the effect of renal replacement therapy (RRT), delivered as hemofiltration vs. hemodialysis, on clinical outcomes in patients with acute kidney injury (AKI). Severe acute kidney injury (AKI) occurs in approximately 6% of patients admitted to an intensive care unit (ICU) [1] and in up to 19% of patients with vasopressordependent septic shock [2]. For such individuals, mortality is approximately 60% [1], and survivors are at. Our objective was to conduct a systematic review and meta-analysis of all RCTs comparing the effects of convective clearance (using hemofiltration) to diffusive clearance (using hemodialysis) in patients with AKI on clinically important outcomes
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