Optimal timing of initiating continuous renal replacement therapy in septic shock patients with acute kidney injury

Abstract

Acute kidney injury (AKI) in patients with septic shock is associated with high mortality, but the appropriate timing for initiating continuous renal replacement therapy (CRRT) is controversial. We retrospectively enrolled 158 septic shock patients with AKI in the medical intensive care unit (ICU) from July 2016 to April 2018. The time from AKI onset to CRRT initiation was compared according to ICU mortality using Cox proportional hazard, receiver operating characteristic, and Kaplan-Meier survival analyses. At the time of ICU discharge, the mortality rate was 50.6% (n = 80). It took longer to initiate CRRT in non-survivors than in survivors (hazard ratio 1.009; 95% confidence interval [CI] 1.003–1.014; P = 0.002). The cut-off time from AKI onset to CRRT initiation for ICU mortality was 16.5 hours (area under the curve 0.786; 95% CI 0.716–0.856; P < 0.001). The cumulative mortality rate was significantly higher in patients in whom CRRT was initiated beyond 16.5 hours after AKI onset than in those in whom CCRT was initiated within 16.5 hours (log-rank test, P < 0.001). Several clinical situations must be considered to determine the optimal timing of CRRT initiation in these patients. Close observation and CRRT initiation within 16.5 hours after AKI onset may help improve survival.

Early versus late initiation of renal replacement therapy impacts mortality in septic patients with acute kidney injury: a meta-analysis

“…4). In cohort studies [25][26][27][28][29][30][31] there was a statistically significant decrease in mortality among patients who received early RRT (OR 0.42; 95% CI 0.30 to 0.40; I 2 21%), while mortality in the RCTs [20,24](OR 1.1; 95% CI 0.84 to 1.45; I 2 0%) was not statistically significant.…”

“…Nine studies [20,[24][25][26][27][28][29][30][31] with a total of 1694 patients ultimately met our criteria (Table 1). These references included two RCTs [20,24] and seven retrospective cohort studies [25][26][27][28][29][30][31]. The characteristics and methodological quality of all trials in the meta-analysis are shown in Table 1 and the outcomes in septic patients with AKI are shown in Table 2.…”

“…The quality of seven cohort studies [25][26][27][28][29][30][31] were evaluated using the Newcastle-Ottawa Scale (NOS) (range 0-9, with 9 indicating the highest quality) ( Table 1).…”

“…Sepsis remains extremely fatal and septic shock has a mortality rate as high as 20-60% worldwide [1][2][3][4][5][6]. Acute kidney injury (AKI) is a frequent complication in septic patients and is closely related to high mortality.…”

“…RRT is known to improve the survival rate of patients with AKI in ICU, because it rectifies metabolic acidosis by removing lactate, regulating unmeasured anions and adjusting levels of phosphate and chloride [10,11]. It is widely consentient that if there are lifethreatening complications for septic patients with AKI, such as hyperkalemia, metabolic acidosis and acute pulmonary edema, RRT should be started immediately [5,[12][13][14][15].…”