Accelerated versus watchful waiting strategy of kidney replacement therapy for acute kidney injury: a systematic review and meta-analysis of randomized clinical trials

Abstract

Background Critically ill patients with severe acute kidney injury (AKI) requiring kidney replacement therapy (KRT) have a grim prognosis. Recently, multiple studies focused on the impact of KRT initiation time (i.e., accelerated vs. watchful waiting KRT initiation [WWS-KRT]) on patient outcomes. We aim to review the results of all related clinical trials. Methods In this systematic review, we searched all relevant randomized clinical trials from January 2000 to April 2021. We assessed the impacts of accelerated vs. WWS-KRT on KRT-dependence, KRT-free days, mortality, and adverse events, including hypotension and infection arrhythmia and bleeding. We rated the certainty of evidence according to Cochrane methods and the GRADE approach. Results A total of 4,932 critically ill patients with AKI from 10 randomized clinical trials were included in this analysis. The overall 28-day mortality rate was 38.5%. The 28-day KRT-dependence rate was 13.0%. The overall incident of KRT in the accelerated group was 97.4%, and 62.8% in the WWS-KRT group. KRT in the accelerated group started 36.7 hours earlier than the WWS-KRT group. The two groups had similar risks of 28-day [pooled log odds ratio (OR): 1.001, p = 0.982] and 90-day (OR: 0.999, p = 0.991) mortality rates. The accelerated group had a significantly higher risk of 90-day KRT dependence (OR: 1.589, p = 0.007), hypotension (OR:1.687, p<0.001), and infection (OR:1.38, p = 0.04) compared with the WWS-KRT group. Conclusions This meta-analysis revealed that accelerated KRT leads to a higher probability of 90-day KRT dependence and dialysis-related complications without any impact on mortality rate when compared with WWS-KRT. Therefore, we suggest the WWS-KRT strategy for critically ill patients.

No difference in mortality after three different kidney replacement therapy initiation strategies in acute kidney injury

“…In brief, by regrouping the KRT initiation strategies, our alternative approach has a result that is in line with a recently published meta-analysis [ 1 ] that no KRT initiation is superior to another regarding mortality. Nevertheless, we would like to note two important uncertainties regarding KRT initiation strategies: uncertainty regarding the safety of the more-delay KRT initiation strategy and uncertainty regarding the optimal KRT initiation strategy for patients with advanced CKD and AKI.…”

“…A meta-analysis examined the benefit of the accelerated kidney replacement therapy (KRT) strategy compared with the watchful waiting KRT initiation strategy in an acute kidney injury (AKI) population [ 1 ] enrolled from the most recent Artificial Kidney Initiation in Kidney Injury 2 (AKIKI 2) trial [ 2 ]. The pairwise meta-analysis categorised the more-delay strategy group in the AKIKI 2 trial into the watchful waiting KRT initiation group.…”

Multiple organ failure in patients with combined breast injury: diagnosis and treatment

“…Таким образом, у пациентов с сепсисом, септическим шоком, полиорганной недостаточностью возможно применение продолжительной/продлённой гемофильтрации/гемодиафильтрации как по «внепочечным показаниям», так и при 1 и 2 стадиях ОПП. Авторы ряда работ предлагают персонифицированный подход к инициации ЗПТ для каждого конкретного пациента с оценкой пользы и возможных рисков [30,31]. В нашей работе МЭГ чаще назначались уже при развитии сепсиса, септического шока и ПОН.…”

Hämoperfusion und Plasmapherese auf der Intensivstation

“…Das Waschen von Blut ist leider komplizierter. Jahrzehnte haben wir benötigt, um zu verstehen, wann mit der Nierenersatztherapie auf der Intensivstation begonnen werden soll [ 8 ]. Nach 10 randomisierten Studien mit 4932 Patient:innen glauben wir, zumindest hierauf eine Antwort gefunden zu haben [ 8 ].…”

“…Jahrzehnte haben wir benötigt, um zu verstehen, wann mit der Nierenersatztherapie auf der Intensivstation begonnen werden soll [ 8 ]. Nach 10 randomisierten Studien mit 4932 Patient:innen glauben wir, zumindest hierauf eine Antwort gefunden zu haben [ 8 ]. Andere Fragen wie die nach dem idealen Verfahren der Nierenersatztherapie bleiben jedoch unbeantwortet.…”