by Heng-Chih Pan, Ying-Ying Chen, I-Jung Tsai, Chih-Chung
Shiao, Tao-Min Huang, Chieh-Kai Chan, Hung-Wei Liao, Tai-Shuan Lai, Yvonne
Chueh, Vin-Cent Wu and Yung-Ming Chen
Critical Care volume 25,
Article number: 5 (2021)
Background
Acute kidney injury (AKI) is a common yet possibly fatal
complication among critically ill patients in intensive care units (ICU).
Although renal replacement therapy (RRT) is an important supportive management
for severe AKI patients, the optimal timing of RRT initiation for these
patients is still unclear.
Methods
In this systematic review, we searched all relevant
randomized controlled trials (RCTs) that directly compared accelerated with
standard initiation of RRT from PUBMED, MEDLINE, EMBASE, and Cnki.net published
prior to July, 20, 2020. We extracted study characteristics and outcomes of
being free of dialysis, dialysis dependence and mortality. We rated the
certainty of evidence according to Cochrane methods and the GRADE approach.
Results
We identified 56 published relevant studies from 1071
screened abstracts. Ten RCTs with 4753 critically ill AKI patients in intensive
care unit (ICU) were included in this meta-analysis. In our study, accelerated
and standard RRT group were not associated with all-cause mortality (log
odds-ratio [OR]: − 0.04, 95% confidence intervals [CI] − 0.16 to 0.07, p = 0.46)
and free of dialysis (log OR: − 0.03, 95% CI − 0.14 to 0.09, p = 0.65). In
the subgroup analyses, accelerated RRT group was significantly associated with
lower risk of all-cause mortality in the surgical ICU and for those who
received continuous renal replacement therapy (CRRT). In addition, patients in
these two subgroups had higher chances of being eventually dialysis-free.
However, accelerated initiation of RRT augmented the risk of dialysis
dependence in the subgroups of patients treated with non-CRRT modality and
whose Sequential Organ Failure Assessment (SOFA) score were more than 11.
Conclusions
In this meta-analysis, critically ill patients with severe
AKI would benefit from accelerated RRT initiation regarding all-cause mortality
and being eventually free of dialysis only if they were surgical ICU patients
or if they underwent CRRT treatment. However, the risk of dialysis dependence
was increased in the accelerated RRT group when those patients used non-CRRT
modality or had high SOFA scores. All the literatures reviewed in this study
were highly heterogeneous and potentially subject to biases.
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