Impact of Early versus Late Initiation of Renal Replacement Therapy in Patients with Cardiac Surgery-Associated Acute Kidney Injury: Meta-Analysis with Trial Sequential Analysis of Randomized Controlled Trials.

Zhen Chen,Jie Cui,Da Tang,Genglong Liu

doi:10.1155/2018/6942829

Abstract

Background Previous studies have examined the effect of the initiation time of renal replacement therapy (RRT) in patients with cardiac surgery-associated acute kidney injury (CSA-AKI), but the findings remain controversial. The aim of this meta-analysis was to systematically and quantitatively compare the impact of early versus late initiation of RRT on the outcome of patients with CSA-AKI. Methods Four databases (PubMed, the Cochrane Library, ISI Web of Knowledge, and Embase) were systematically searched from inception to June 2018 for randomized clinical trials (RCTs). Two investigators independently performed the literature search, study selection, data extraction, and quality evaluation. Meta-analysis and trial sequential analysis (TSA) were used to examine the impact of RRT initiation time on all-cause mortality (primary outcome). The Grading of Recommendations Assessment Development and Evaluation (GRADE) was used to evaluate the level of evidence. Results We identified 4 RCTs with 355 patients that were eligible for inclusion. Pooled analyses indicated no difference in mortality for patients receiving early and late initiation of RRT (relative risk [RR] = 0.61, 95% confidence interval [CI] = 0.33 to 1.12). However, the results were not confirmed by TSA. Similarly, early RRT did not reduce the length of stay (LOS) in the intensive care unit (ICU) (mean difference [MD] = -1.04; 95% CI = -3.34 to 1.27) or the LOS in the hospital (MD = -1.57; 95% CI = -4.62 to 1.48). Analysis using GRADE indicated the certainty of the body of evidence was very low for a benefit from early initiation of RRT. Conclusion Early initiation of RRT had no beneficial impacts on outcomes in patients with CSA-AKI. Future larger and more adequately powered prospective RCTs are needed to verify the benefit of reduced mortality associated with early initiation of RRT. Trial Registration This trial is registered with PROSPERO registration number CRD42018084465, registered on 11 February 2018.

Highlights

Previous studies have examined the effect of the initiation time of renal replacement therapy (RRT) in patients with cardiac surgery-associated acute kidney injury (CSA-AKI), but the findings remain controversial
After removal of 2021 duplicates, we examined the titles and abstracts of the remaining 955 papers and eliminated 915 of them based on our eligibility criteria
Pooled estimates indicated no significant survival benefit for early RRT (RR = 0.61, 95% CI = 0.33 to 1.12) (Figure 2)

Summary

Introduction

Previous studies have examined the effect of the initiation time of renal replacement therapy (RRT) in patients with cardiac surgery-associated acute kidney injury (CSA-AKI), but the findings remain controversial. The aim of this meta-analysis was to systematically and quantitatively compare the impact of early versus late initiation of RRT on the outcome of patients with CSAAKI. Meta-analysis and trial sequential analysis (TSA) were used to examine the impact of RRT initiation time on all-cause mortality (primary outcome). Acute kidney injury (AKI) occurs in 5% to 42% of patients after cardiac surgery (depending on how AKI is defined) and is associated with increased morbidity, length of hospital stay, cost of care, and mortality [2,3,4,5]. Two meta-analyses have examined this topic [14, 15] and reported a benefit of earlier initiation of RRT for these patients, but these conclusions were based on many lowquality observational studies

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Results

Discussion

Conclusion