Early Renal Replacement Therapy Group Research Articles

Comparison of early and delayed strategy for renal replacement therapy initiation for severe acute kidney injury with heart failure: a retrospective comparative cohort study.

Determining the timing of renal replacement therapy (RRT) in patients with acute kidney injury (AKI) and heart failure (HF) can optimize the clinical management strategy. We compared the impact of "early" and "delayed" timing of RRT on the prognosis of patients with AKI and HF. Clinical data from September 2012 to September 2022 were retrospectively analyzed. Patients with AKI complicated by HF and undergoing RRT in the intensive care unit (ICU) were enrolled. Patients with stage 3 AKI and fluid overload present (FOP) or who met the emergency indications for RRT were assigned to the delayed RRT group. Patients with stage 1 AKI or stage 2 AKI and without urgent indications for RRT and patients with stage 3 AKI without FOP and without urgent indications for RRT were enrolled in the Early RRT group. At 90-day follow-up after initiation of RRT, the mortality was compared between the two groups. Logistic regression analysis was performed to adjust for confounding factors affecting 90-day mortality. A total of 151 patients were enrolled, including 77 in the early RRT group and 74 in the delayed RRT group. For baseline characteristics, patients in the early RRT group had significantly lower acute physiology and chronic health evaluation-II (APACHE-II) score, sequential organ failure assessment (SOFA), serum creatinine (Scr) values and blood urea nitrogen (BUN) values on the day of ICU admission than those in the delayed RRT group (both P values <0.05), there were no significant differences in other baseline characteristics. The number of RRT-free days in the ICU was significantly longer in the early RRT group than in the delayed RRT group [1.69 (0.35-10.87) vs. 0.88 (0.20-4.55) days; P=0.046]. However, clinical outcomes (except for the number of RRT-free days) and complications showed no significant differences between these 2 groups (all P values >0.05). Multivariate binary logistic regression analysis showed early initiation of RRT was not an independent risk factor for increased 90-day mortality [odds ratio (OR): 0.671; 95% confidence interval (CI): 0.314-1.434; P=0.303]. Early initiation of RRT is not recommended to reduce mortality in AKI patients with HF.

Timing of renal replacement therapy initiation for acute kidney injury in critically ill patients: a systematic review of randomized clinical trials with meta-analysis and trial sequential analysis

BackgroundAcute kidney injury (AKI) is a common serious complication in critically ill patients. AKI occurs in up to 50% patients in intensive care unit (ICU), with poor clinical prognosis. Renal replacement therapy (RRT) has been widely used in critically ill patients with AKI. However, in patients without urgent indications such as acute pulmonary edema, severe acidosis, and severe hyperkalemia, the optimal timing of RRT initiation is still under debate. We conducted this systematic review of randomized clinical trials (RCTs) with meta-analysis and trial sequential analysis (TSA) to compare the effects of early RRT initiation versus delayed RRT initiation.MethodsWe searched databases (PubMed, EMBASE and Cochrane Library) from inception through to July 20, 2020, to identify eligible RCTs. The primary outcome was 28-day mortality. Two authors extracted the data independently. When the I2 values < 25%, we used fixed-effect mode. Otherwise, the random effects model was used as appropriate. TSA was performed to control the risk of random errors and assess whether the results in our meta-analysis were conclusive.ResultsEleven studies involving 5086 patients were identified. Two studies included patients with sepsis, one study included patients with shock after cardiac surgery, and eight others included mixed populations. The criteria for the initiation of RRT, the definition of AKI, and RRT modalities existed great variations among the studies. The median time of RRT initiation across studies ranged from 2 to 7.6 h in the early RRT group and 21 to 57 h in the delayed RRT group. The pooled results showed that early initiation of RRT could not decrease 28-day all-cause mortality compared with delayed RRT (RR 1.01; 95% CI 0.94–1.09; P = 0.77; I2 = 0%). TSA result showed that the required information size was 2949. The cumulative Z curve crossed the futility boundary and reached the required information size. In addition, early initiation of RRT could lead to unnecessary RRT exposure in some patients and was associated with a higher incidence of hypotension (RR 1.42; 95% CI 1.23–1.63; P < 0.00001; I2 = 8%) and RRT-associated infection events (RR 1.34; 95% CI 1.01–1.78; P = 0.04; I2 = 0%).ConclusionsThis meta-analysis suggested that early initiation of RRT was not associated with survival benefit in critically ill patients with AKI. In addition, early initiation of RRT could lead to unnecessary RRT exposure in some patients, resulting in a waste of health resources and a higher incidence of RRT-associated adverse events. Maybe, only critically ill patients with a clear and hard indication, such as severe acidosis, pulmonary edema, and hyperkalemia, could benefit from early initiation of RRT.

Comparison of Standard Conservative Treatment and Early Initiation of Renal Replacement Therapy in Pregnancy-related Acute Kidney Injury: A Single-center Prospective Study.

Introduction and objectivePregnancy-related acute kidney injury (PRAKI) is one of the most important cause of maternal and fetal morbidity and mortality. Some of the reasons behind PRAKI may be due to sepsis, postpartum hemorrhage, preeclampsia, thrombotic microangiopathies (TMA), and acute fatty liver of pregnancy (AFLP). The timing of initiation of renal replacement therapy (RRT) for better patient outcome is still debatable. We conducted this study to establish whether earlier initiation of RRT in PRAKI improves fetomaternal survival compared to a more conservative approach.Materials and methodsThis is a prospective study, where patients were screened at a multispecialty tertiary care hospital in north India for 1 year. The patients were divided into two groups: early RRT and standard AKI treatment. The demographic profile and clinical characteristics of the patients in terms of age, parity access to antenatal care, fetal outcome, urine output, hematological and biochemical profiles, RRT, duration of hospitalization, recovery of renal function, and patients survival were recorded.ResultsThis prospective study conducted included 13 patients in the early RRT group and 23 patients in the standard group. Considering the fetal outcome, the number of fetal deaths in early RRT group were 14.29%, whereas for the standard group it was 85.71%. In all, 75% of early RRT group and 25% of standard group had normal term delivery. Probability test applied showed they were statistically significant. One maternal mortality was there in the standard group. The indices of maternal outcome in PRAKI patients were found to be statistically insignificant.ConclusionThe planning of RRT whether early or late does not make a difference in maternal mortality or morbidity. The fetal outcome is significantly better for patients with early RRT than conservative treatment in PRAKI.How to cite this articleBanerjee A, Mehrotra G. Comparison of Standard Conservative Treatment and Early Initiation of Renal Replacement Therapy in Pregnancy-related Acute Kidney Injury: A Single-center Prospective Study. Indian J Crit Care Med 2020;24(8):688–694.

Delayed versus early initiation of renal replacement therapy for severe acute kidney injury: a systematic review and individual patient data meta-analysis of randomised clinical trials

The timing of renal replacement therapy (RRT) for severe acute kidney injury is highly debated when no life-threatening complications are present. We assessed whether a strategy of delayed versus early RRT initiation affects 28-day survival in critically ill adults with severe acute kidney injury. In this systematic review and individual patient data meta-analysis, we searched MEDLINE (via PubMed), Embase, and the Cochrane Central Register of Controlled Trials for randomised trials published from April 1, 2008, to Dec 20, 2019, that compared delayed and early RRT initiation strategies in patients with severe acute kidney injury. Trials were eligible for inclusion if they included critically ill patients aged 18 years or older with acute kidney injury (defined as a Kidney Disease: Improving Global Outcomes [KDIGO] acute kidney injury stage 2 or 3, or, where KDIGO was unavailable, a renal Sequential Organ Failure Assessment score of 3 or higher). We contacted the principal investigator of each eligible trial to request individual patient data. From the included trials, any patients without acute kidney injury or who were not randomly allocated were not included in the individual patient data meta-analysis. The primary outcome was all-cause mortality at day 28 after randomisation. This study is registered with PROSPERO (CRD42019125025). Among the 1031 studies identified, one study that met the eligibility criteria was excluded because the recruitment period was not recent enough, and ten (including 2143 patients) were included in the analysis. Individual patient data were available for nine studies (2083 patients), from which 1879 patients had severe acute kidney injury and were randomly allocated: 946 (50%) to the delayed RRT group and 933 (50%) to the early RRT group. 390 (42%) of 929 patients allocated to the delayed RRT group and who had available data did not receive RRT. The proportion of patients who died by day 28 did not significantly differ between the delayed RRT group (366 [44%] of 837) and the early RRT group (355 [43%] of 827; risk ratio 1·01 [95% CI 0·91 to 1·13], p=0·80), corresponding to an overall risk difference of 0·01 (95% CI -0·04 to 0·06). There was no heterogeneity across studies (I2=0%; τ2=0), and most studies had a low risk of bias. The timing of RRT initiation does not affect survival in critically ill patients with severe acute kidney injury in the absence of urgent indications for RRT. Delaying RRT initiation, with close patient monitoring, might lead to a reduced use of RRT, thereby saving health resources. None.

Comparison between watchful waiting strategy and early initiation of renal replacement therapy in the critically ill acute kidney injury population: an updated systematic review and meta-analysis

BackgroundThe optimal timing of renal replacement therapy (RRT) initiation is debatable. Many articles in this field enrolled trials not based on acute kidney injury. The safety of the watchful waiting strategy has not been fully discussed, and late RRT initiation criteria vary across studies. The effect of early RRT initiation in the AKI population with high plasma neutrophil gelatinase-associated lipocalin (NGAL) has not been examined yet.MethodsIn accordance with PRISMA guidelines, the PubMed, Embase, and Cochrane databases were systemically searched for randomized controlled trials (RCTs). Trials not conducted in the AKI population were excluded. Data of study characteristics, primary outcome (all-cause mortality), and related secondary outcomes [mechanical ventilation (MV) days, length of hospital stay, RRT days, and length of ICU stay] were extracted. The outcomes were compared between early and late RRT groups by estimating the pooled odds ratio (OR) for binary outcomes and the weighted mean difference for continuous outcomes. Prospective trials were also examined and analyzed using the same method.ResultsNine RCTs with 1938 patients were included. Early RRT did not provide a survival benefit (pooled OR, 0.88; 95% confidence interval [CI] 0.62–1.27). However, the early RRT group had significantly fewer MV days (pooled mean difference, − 3.98 days; 95% CI − 7.81 to − 0.15 days). Subgroup analysis showed that RCTs enrolling the surgical population (P = .001) and the AKI population with high plasma NGAL (P = .031) had favorable outcomes regarding RRT days in the early initiation group. Moreover, 6 of 9 RCTs were selected for examining the safety of the watchful waiting strategy, and no significant differences were found in primary and secondary outcomes between the early and late RRT groups.ConclusionsOverall, early RRT initiation did not provide a survival benefit, but a possible benefit of fewer MV days was detected. Early RRT might also provide the benefit of shorter MV or RRT support in the surgical population and in AKI patients with high plasma NGAL. Depending on the conventional indication for RRT initiation, the watchful waiting strategy is safe on the basis of all primary and secondary outcomes.

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

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.

The effect of renal replacement therapy timing on the outcome of acute kidney injury in critically ill patients

Introduction The timing of renal replacement therapy (RRT) initiation in patients having acute kidney disease has been a controversial issue for many years. A recently published systematic review and meta-analysis on this topic failed to demonstrate measurable benefits of early RRT. Patients and methods We compared RRT initiation timing in critically ill patients and defined early or late RRT in reference to the timing after which stage 3 Acute Kidney Injury Network criteria were met. Patients beginning RRT within 24 h after reaching stage 3 acute kidney injury (AKI) were considered early starters, whereas those beginning RRT past 24 h after reaching stage 3 AKI were considered late starters. Acute Kidney Injury Network criteria were evaluated by both urine output and serum creatinine. Patients with acute-on-chronic kidney disease were excluded. A propensity score methodology was used to control variables. Results A total of 123 critically ill patients were subjected to RRT. Only 40 patients with pure stage 3 AKI were analyzed. Mortality was lower in the early RRT group than in the late RRT group (18.6 vs. 81.1%, P=0.000). Moreover, patients in the early RRT group had a lower duration of mechanical ventilation, RRT duration, vasopressor duration, and ICU discharge creatinine level. Conclusion Using a time-based approach could be a better means of assessing the association between RRT initiation and outcomes in patients with AKI. In patients with stage 3 AKI, RRT initiation within 24 h should be considered.

Role of acute kidney injury biomarkers to guide renal replacement therapy initiation, what we learn from EARLY-RRT trial and FST trial?

We wrote this letter to the editor in response to the commentary by Hoste et al ., and Meersch et al ., on our trial “The effect of early Renal Replacement Therapy guided by plasma Neutrophil Gelatinase Associated Lipocalin on outcome of Acute Kidney Injury: a feasibility study (EARLY-RRT)” trial which was recently published in the J Crit Care (1). In brief, we divided the study into two phases, triage and interventional phase, running subsequently. As a guide for triage to renal replacement therapy (RRT), we measured plasma neutrophil gelatinase associated lipocalin (pNGAL) at the enrollment time. Forty patients with pNGAL ≥400 ng/mL (high pNGAL group) were randomized to ‘early’ or ‘standard’ group. Patients with pNGAL <400 ng/mL (n=20) were defined as low pNGAL group. The triggering pNGAL selected acute kidney injury (AKI) patients with more severity of illness and worse clinical outcome. However, in high pNGAL group, early RRT did not result in different 28-day mortality from the standard group. The median numbers of day free from mechanical ventilation were significantly higher in the early RRT group.

Timing of Renal Replacement Therapy and its impact on the Outcome of Acute Kidney Injury Patients

Background: Previous studies using Acute Kidney Injury Network (AKIN)/RIFLE criteria to classify early initiation of renal replacement therapy (RRT) have defined it as the therapy started in less severe AKIN/RIFLE stages. Generally, these studies failed in demonstrating measurable benefits. Aim: To evaluate RRT in critically ill patients and its timing and its impact on critically ill patients. Methods: We compared RRT initiation in critically ill patients and defined early or late RRT in reference to timing after stage 3 AKIN was met: patients beginning RRT within 24 hours after acute kidney injury (AKI) stage 3 were considered early starters. AKIN criteria were evaluated by both urine output (UO) and serum creatinine (sCr) and patients with acute-on-chronic kidney disease were excluded. A propensity score methodology was used to control variables. Results: A total of 358 critically ill patients were submitted to RRT. Only 150 patients with pure AKI at stage 3 were analyzed. Mortality was lower in the early RRT group (51.5 vs. 77.9%, P = 0.001). After achieving balance between the groups using a propensity score, there was a significant 30.5 (95% confidence interval [CI] 14.4 to 45.2%, P = 0.002) relative decrease of mortality in the early RRT group. Moreover, patients on the early RRT group had lower duration of mechanical ventilation, time on RRT and a trend to lower intensive care unit (ICU) length of stay. Conclusions: For the first time, AKIN was used with UO criterion to evaluate early and late RRT. Using a time based approach could be a better parameter to access the association between RRT initiation and outcomes in patients with AKI.

Early versus standard initiation of renal replacement therapy in furosemide stress test non-responsive acute kidney injury patients (the FST trial)

BackgroundThe timing of initiation of renal replacement therapy (RRT) in severe acute kidney injury (AKI) remains controversial, with early initiation resulting in unnecessary therapy for some patients while expectant therapy may delay RRT for other patients. The furosemide stress test (FST) has been shown to predict the need for RRT and therefore could be used to exclude low-risk patients from enrollment in trials of RRT timing. We conducted this multicenter pilot study to determine whether FST could be used to screen patients at high risk for RRT and to determine the feasibility of incorporating FST into a trial of early initiation of RRT.MethodsFST was performed using intravenous furosemide (1 mg/kg in furosemide-naive patients or 1.5 mg/kg in previous furosemide users). FST-nonresponsive patients (urine output less than 200 mL in 2 h) were then randomized to early (initiation within 6 h) or standard (initiation by urgent indication) RRT.ResultsFST was completed in all patients (100%). Only 6/44 (13.6%) FST-responsive patients ultimately received RRT while 47/60 (78.3%) nonresponders randomized to standard RRT either received RRT or died (P < 0.001). Among 118 FST-nonresponsive patients, 98.3% in the early RRT arm and 75% in the standard RRT arm received RRT. The adherence to the protocol was 94.8% and 100% in the early and standard RRT group, respectively. We observed no differences in 28-day mortality (62.1 versus 58.3%, P = 0.68), 7-day fluid balance, or RRT dependence at day 28. However, hypophosphatemia occurred more frequently in the early RRT arm (P = 0.002).ConclusionThe furosemide stress test appears to be feasible and effective in identifying patients for randomization to different RRT initiation times. Our findings should guide implementation of large-scale randomized controlled trials for the timing of RRT initiation.Trial registrationclinicaltrials.gov, NCT02730117. Registered 6 April 2016.

Timing of renal replacement therapy and long-term risk of chronic kidney disease and death in intensive care patients with acute kidney injury

BackgroundThe optimal time to initiate renal replacement therapy (RRT) in intensive care unit (ICU) patients with acute kidney injury (AKI) is unclear. We examined the impact of early RRT on long-term mortality, risk of chronic kidney disease (CKD), and end-stage renal disease (ESRD).MethodsThis cohort study included all adult patients treated with continuous RRT in the ICU at Aarhus University Hospital, Skejby, Denmark (2005–2015). Data were obtained from a clinical information system and population-based registries. Early treatment was defined as RRT initiation at AKI stage 2 or below, and late treatment was defined as RRT initiation at AKI stage 3. Inverse probability of treatment (IPT) weights were computed from propensity scores. The IPT-weighted cumulative risk of CKD (estimated glomerular filtration rate < 60 ml/minute/1.73 m2), ESRD, and mortality was estimated and compared using IPT-weighted Cox regression.ResultsThe mortality, CKD, and ESRD analyses included 1213, 303, and 617 patients, respectively. The 90-day mortality in the early RRT group was 53.6% compared with 46.0% in the late RRT group (HR 1.24, 95% CI 1.03–1.48). The 90-day to 5-year mortality was 37.7% and 41.5% in the early and late RRT groups, respectively (HR 0.95, 95% CI 0.70–1.29). The 5-year risk of CKD was 35.9% in the early RRT group and 44.9% in the late RRT group (HR 0.74, 95% CI 0.46–1.18). The 5-year risk of ESRD was 13.3% in the early RRT group and 16.7% in the late RRT group (HR 0.79, 95% CI 0.47–1.32).ConclusionsEarly initiation was associated with increased 90-day mortality. In patients surviving to day 90, early initiation was not associated with a major impact on long-term mortality or risk of CKD and ESRD. Despite potential residual confounding due to the observational design, our findings do not support that early RRT initiation is superior to late initiation.

The effect of early renal replacement therapy guided by plasma neutrophil gelatinase associated lipocalin on outcome of acute kidney injury: A feasibility study

PurposeThe optimal time and the parameter utilized for decision to initiate renal replacement therapy (RRT) in acute kidney injury (AKI) are still controversial. Recently, high levels of plasma NGAL (pNGAL) has been strongly correlated with poor AKI outcome. This is a feasibility study conducted to test whether early RRT initiation guided by pNGAL could improve AKI outcome. Material and methodsThe study comprised of triage trial and interventional trial running subsequently. As a guide for triage to RRT, we measured pNGAL at the enrollment time. Forty patients with pNGAL≥400ng/mL (high pNGAL group) were randomized to ‘early’ or ‘standard’ group. Patients with pNGAL<400ng/mL (n=20) were defined as low pNGAL group. ResultsThe triggering pNGAL selected AKI patients with more severity of illness and worse clinical outcome. However, in high pNGAL group, early RRT did not result in different 28-day mortality from the standard group. The median numbers of day free from mechanical ventilation were significantly higher in the early RRT group. ConclusionsOur finding suggested that it was feasible to use pNGAL to triage severe AKI patients. However, early initiation of RRT in this high risk group did not affect the 28-day mortality.

The effect of early versus late initiation of renal replacement therapy in patients with acute kidney injury: A meta-analysis with trial sequential analysis of randomized controlled trials

BackgroundThe optimal timing for initiating renal replacement therapy (RRT) in patients with acute kidney injury (AKI) remains controversial.MethodsWe conducted a meta-analysis with trial sequential analysis (TSA) of randomized controlled trials (RCTs) using PUBMED, Cochrane Library databases, and Web of Science (from January 1, 1985, to August 21, 2016). Adult patients with AKI who received RRT with different timing were included. The primary outcome was mortality. The secondary outcomes were intensive care unit (ICU) length of stay (LOS) and hospital LOS.ResultsWe included 9 RCTs with a total of 1636 participants. No differences between the early RRT group and the late RRT group were found with respect to mortality (38% vs 41.4%; relative risk, 0.93; 95% confidence interval [CI], 0.74–1.18). However, TSA showed that the cumulative Z-curve did not cross either the conventional boundary for benefit or the trial sequential monitoring boundary, indicating insufficient evidence. Similarity, there were no findings of benefits in terms of reduction in the ICU LOS (standard difference in the means, −0.32 days; 95% CI, −0.71 to 0.07 days) and hospital LOS (standard difference in the means, −1.11 days; 95% CI, −2.28 to 0.06 days). Meanwhile, the results of TSA did not confirm this conclusion.ConclusionsAlthough conventional meta-analysis showed that early initiation of RRT in patients with AKI was not associated with decreased mortality, ICU LOS and hospital LOS, TSA indicated that the data were far too sparse to make any conclusions. Therefore, well-designed, large RCTs are needed.

Effect of timing of initiation of renal replacement therapy on prognosis in septic patients with acute kidney injury: a Meta analysis

To systemically review the effects of timing of initiation of renal replacement therapy (RRT) on prognosis in septic patients with acute kidney injury (AKI). A systematic search for randomized controlled trials (RCTs) and other clinical studies focused on comparing varied timing of initiation of RRT in septic AKI patients was performed in English or Chinese from PubMed, Web of Science, EMBASE, CNKI, Wanfang data, VIP from January 2000 to July 2014. Data screened were extracted with Cochrane systemically review method, and enrolled literature was collected for Meta analysis with RevMan 5.2 software. Total mortality, 28-day mortality, the total length of hospital stay and intensive care unit (ICU) stay in septic AKI patients with early or late initiation of RRT was analyzed. Funnel plots were drawn to detect publication bias. Five retrospective comparative studies with a total of 885 patients were enrolled. Random effect model in Meta analysis showed that there was no significant difference in total mortality between early RRT group and late RRT group [65.7% (226/344) vs. 68.7% (239/348), odds ratio (OR) = 0.71, 95% confidence interval (95%CI) = 0.38-1.31, P = 0.27]. The funnel plot demonstrated publication bias. Fixed effect model showed that there was significant difference in 28-day mortality between early RRT group and late RRT group [43.4% (66/152) vs. 55.3% (94/170), OR = 0.59, 95% CI = 0.36-0.94, P = 0.03 ]. The funnel plot demonstrated publication bias too. The data of total length of hospital stay and ICU stay could not be Meta-analyzed because of different data distribution, but no differences in total length of hospital stay and ICU stay between early and late RRT groups for septic AKI patients were found. Early RRT could reduce the 28-day mortality in patients with septic AKI compared with late RRT, but it did not lower the total mortality.

Early versus late initiation of renal replacement therapy in critically ill patients with acute kidney injury after cardiac surgery: a systematic review and meta-analysis.

To investigate the impact of early versus late renal replacement therapy (RRT) on mortality in patients with acute kidney injury (AKI) after cardiac surgery. Meta-analysis of 9 retrospective cohort studies and 2 randomized clinical trials extracted from the Medline engine from 1950 to 2013. University medical school. 841 Patients. None. A total of 841 patients were studied. Pooled estimates of the odds ratio with 95% confidence interval using a random-effect model were conducted as well as the heterogeneity, publication bias, and sensitivity analysis. Primary outcome was 28-day mortality, and secondary outcome was the intensive care unit (ICU) length of stay. The 28-days mortality rate was lower in the early RRT group (OR = 0.29, 95% CI, 0.16-0.52, p<0.0001, NNT = 5). Heterogeneity was high (I2 = 56%), and publication bias was low. Secondary outcome suggested 3.9 (1.5-6.3) days shorter ICU stay in the early RRT group, p<0.0001, with extremely high heterogeneity (I(2) = 99%), and low publication bias. Specifically, studies before 2000 and studies with mortality less than 50% in the late RRT group reported significantly higher odds ratio and mean difference than overall value favoring early RRT. Early initiation of RRT for patients with AKI after cardiac surgery revealed lower 28-days mortality and shorter ICU length of stay. However, this was based on 11 studies of various qualities with very high heterogeneity of results. Defining treatment guidelines needs further research with a larger and better database.

Timing of renal replacement therapy initiation by AKIN classification system.

IntroductionPrevious studies using Acute Kidney Injury Network (AKIN)/RIFLE criteria to classify early initiation of renal replacement therapy (RRT) have defined it as the therapy started in less severe AKIN/RIFLE stages. Generally, these studies failed in demonstrating measurable benefits.MethodsWe compared RRT initiation in critically ill patients and defined early or late RRT in reference to timing after stage 3 AKIN was met: patients beginning RRT within 24 hours after acute kidney injury (AKI) stage 3 were considered early starters. AKIN criteria were evaluated by both urine output (UO) and serum creatinine (sCr) and patients with acute-on-chronic kidney disease were excluded. A propensity score methodology was used to control variables.ResultsA total of 358 critically ill patients were submitted to RRT. Only 150 patients with pure AKI at stage 3 were analyzed. Mortality was lower in the early RRT group (51.5 vs. 77.9%, P = 0.001). After achieving balance between the groups using a propensity score, there was a significant 30.5 (95% confidence interval [CI] 14.4 to 45.2%, P = 0.002) relative decrease of mortality in the early RRT group. Moreover, patients on the early RRT group had lower duration of mechanical ventilation, time on RRT and a trend to lower intensive care unit (ICU) length of stay.ConclusionsFor the first time, AKIN was used with UO criterion to evaluate early and late RRT. Using a time-based approach could be a better parameter to access the association between RRT initiation and outcomes in patients with AKI.