Abstract
BackgroundThe optimal timing of initiating renal replacement therapy (RRT) in critical illness complicated by acute kidney injury (AKI) is not clearly established. Trials completed on this topic have been marked by contradictory findings as well as quality and heterogeneity issues. Our goal was to perform a synthesis of the evidence regarding the impact of “early” versus “late” RRT in critically ill patients with AKI, focusing on the highest-quality research on this topic.MethodsA literature search using the PubMed and Embase databases was completed to identify studies involving critically ill adult patients with AKI who received hemodialysis according to “early” versus “late”/“standard” criteria. The highest-quality studies were selected for meta-analysis. The primary outcome of interest was mortality at 1 month (composite of 28- and 30-day mortality). Secondary outcomes evaluated included intensive care unit (ICU) and hospital length of stay (LOS).ResultsThirty-six studies (seven randomized controlled trials, ten prospective cohorts, and nineteen retrospective cohorts) were identified for detailed evaluation. Nine studies involving 1042 patients were considered to be of high quality and were included for quantitative analysis. No survival advantage was found with “early” RRT among high-quality studies with an OR of 0.665 (95 % CI 0.384–1.153, p = 0.146). Subgroup analysis by reason for ICU admission (surgical/medical) or definition of “early” (time/biochemical) showed no evidence of survival advantage. No significant differences were observed in ICU or hospital LOS among high-quality studies.ConclusionsOur conclusion based on this evidence synthesis is that “early” initiation of RRT in critical illness complicated by AKI does not improve patient survival or confer reductions in ICU or hospital LOS.Electronic supplementary materialThe online version of this article (doi:10.1186/s13054-016-1291-8) contains supplementary material, which is available to authorized users.
Highlights
The optimal timing of initiating renal replacement therapy (RRT) in critical illness complicated by acute kidney injury (AKI) is not clearly established
The Sequential Organ Failure Assessment (SOFA) score has been correlated with critical care patient outcomes [47, 48], but it is not as robust as other scoring systems validated in predicting survival (e.g., Acute Physiology and Chronic Health Evaluation II [APACHE2] or Simplified Acute Physiology Score II [SAPS2]) [49]
Among the high-quality studies, the SOFA score appeared to correspond with an APACHE2 score of approximately 20 or a SAPS2 score of approximately 53 when these additional illness severity metrics were reported by the principal investigators
Summary
The optimal timing of initiating renal replacement therapy (RRT) in critical illness complicated by acute kidney injury (AKI) is not clearly established. Trials completed on this topic have been marked by contradictory findings as well as quality and heterogeneity issues. Acute kidney injury (AKI) is a medical complication associated with significant morbidity and mortality in critically ill patients [1,2,3]. Research into “early” RRT includes multiple definitions of early that reflect a potpourri of time factors, biochemical markers, and clinical parameters in an attempt to balance the risks of initiating RRT with the benefits expected from supporting renal function during critical illness
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