Dataset Information

Timing of initiation of renal replacement therapy in acute kidney injury: an updated meta-analysis of randomized controlled trials.

ABSTRACT: Purpose: The results from randomized controlled trials (RCTs) concerning the timing of initiation of renal replacement therapy (RRT) for patients with acute kidney injury (AKI) are still inconsistent.Materials and methods: We searched for RCTs, as well as relevant references, focusing on the timing of RRT for AKI patients in the Medline, Embase, Cochrane Library, Google Scholar and Chinese databases from their inception to December 2018.Results: We included 18 RCTs from 1997 to 2018 involving 2856 patients. Pooled analyses of all RCTs showed no significant difference in mortality between early initiation and delayed initiation of RRT (RR 0.98, 95% CI: 0.89 to 1.08, p = .7) (I2 = 2%), and similar results were found in critically ill and community-acquired AKI patients, as well as in a subgroup of patients with sepsis and in cardiac surgery recipients. There was also no difference in the incidence of dialysis independence (RR 0.75, 95% CI: 0.47 to 1.2, p = .2) (I2 = 0). However, an early RRT strategy was associated with a significantly higher incidence of the need for RRT for AKI patients (RR 1.24, 95% CI: 1.13 to 1.36, p < .01) (I2 = 34%).Conclusions: As no life-threatening complications occurred, there was no evidence to show any benefit of an early RRT strategy for critically ill or community-acquired AKI patients; in contrast, a delayed strategy might avert the need for RRT.

SUBMITTER: Zhang L

PROVIDER: S-EPMC6968507 | biostudies-literature |

REPOSITORIES: biostudies-literature

ACCESS DATA

Similar Datasets

Project description: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.

Project description:BackgroundPostoperative acute kidney injury (AKI) is associated with poor outcomes in surgical patients. This study aims to evaluate whether the timing of renal replacement therapy (RRT) initiation affects the in-hospital mortality of patients with postoperative AKI.MethodologyThis multicenter retrospective observational study, which was conducted in the intensive care units (ICUs) in a tertiary hospital (National Taiwan University Hospital) and its branch hospitals in Taiwan between January, 2002, and April, 2009, included adult patients with postoperative AKI who underwent RRT for predefined indications. The demographic data, comorbid diseases, types of surgery and RRT, and the indications for RRT were documented. Patients were categorized according to the period of time between the ICU admission and RRT initiation as the early (EG, ?1 day), intermediate (IG, 2-3 days), and late (LG, ?4 days) groups. The in-hospital mortality rate censored at 180 day was defined as the endpoint.ResultsSix hundred forty-eight patients (418 men, mean age 63.0±15.9 years) were enrolled, and 379 patients (58.5%) died during the hospitalization. Both the estimated probability of death and the in-hospital mortality rates of the three groups represented U-curves. According to the Cox proportional hazard method, LG (hazard ratio, 1.527; 95% confidence interval, 1.152-2.024; P?=?0.003, compared with IG group), age (1.014; 1.006-1.021), diabetes (1.279; 1.022-1.601; P?=?0.031), cirrhosis (2.147; 1.421-3.242), extracorporeal membrane oxygenation support (1.811; 1.391-2.359), initial neurological dysfunction (1.448; 1.107-1.894; P?=?0.007), pre-RRT mean arterial pressure (0.988; 0.981-0.995), inotropic equivalent (1.006; 1.001-1.012; P?=?0.013), APACHE II scores (1.055; 1.037-1.073), and sepsis (1.939; 1.536-2.449) were independent predictors of the in-hospital mortality (All P<0.001 except otherwise stated).ConclusionsThe current study found a U-curve association between the timing of the RRT initiation after the ICU admission and patients' in-hospital mortalities, and alerts physicians of certain factors affecting the outcome after the RRT initiation.

Project description:BACKGROUND:The 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. METHODS:In 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. RESULTS:Nine 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. CONCLUSIONS:Overall, 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.

Dataset Information

Timing of initiation of renal replacement therapy in acute kidney injury: an updated meta-analysis of randomized controlled trials.

Similar Datasets

OmicsDI is part of the ELIXIR infrastructure

Tweets