Timing of Initiation of Renal Replacement Therapy in Acute Kidney Injury: A Systematic Review and Meta-analysis

Wang, Xuan; Yuan, Wei

doi:10.3109/0886022x.2011.647371

Cited by 48 publications

(32 citation statements)

References 25 publications

(57 reference statements)

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“…However, this is of great importance, since mode, timing, dose and other device settings may have an impact on its efficacy and patient outcome [29-31]. As long as 'need for RRT' is a study endpoint, indication for RRT should clearly be specified.…”

Section: Resultsmentioning

confidence: 99%

“…Further, RRT is not a single homogeneous therapy but rather there are diverse modes of therapy and various ways of providing RRT that might affect its efficacy and patient outcome [29-31]. These aspects refers to the mode (intermittent vs. continuous), timing of RRT initiation and discontinuation, dose, and practice variations (type of dilution, type of anticoagulation, and so on).…”

Section: Resultsmentioning

confidence: 99%

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Re-evaluating currently available data and suggestions for planning randomised controlled studies regarding the use of hydroxyethyl starch in critically ill patients - a multidisciplinary statement

et al. 2013

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IntroductionHydroxyethyl starch (HES) is a commonly used colloid in critically ill patients. However, its safety has been questioned in recent studies and meta-analyses.MethodsWe re-evaluated prospective randomised controlled trials (RCT) from four meta-analyses published in 2013 that compared the effect of HES with crystalloids in critically ill patients, focusing on the adherence to 'presumably correct indication'. Regarding the definition of 'presumably correct indication', studies were checked for the following six criteria (maximum six points): short time interval from shock to randomisation (<6 h), restricted use for initial volume resuscitation, use of any consistent algorithm for haemodynamic stabilisation, reproducible indicators of hypovolaemia, maximum dose of HES, and exclusion of patients with pre-existing renal failure or renal replacement therapy.ResultsDuration of fluid administration ranged from 90 min up to a maximum of 90 days. Four studies considered follow-up until 90-day mortality, three studies 28-/30-day mortality, whereas four studies reported only early mortality. Included studies showed a large heterogeneity of the indication score ranging between 1 and 4 points with a median (25%; 75% quartile) of 4 (2; 4).ConclusionsThe most important question, whether or not HES may be harmful when it is limited to immediate haemodynamic stabilisation, cannot be answered yet in the absence of any study sufficiently addressing this question. In order to overcome the limitations of most of the previous studies, we now suggest an algorithm emphasising the strict indication of HES. Additionally, we give a list of suggestions that should be adequately considered in any prospective RCT in the field of acute volume resuscitation in critically ill patients.

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Section: Resultsmentioning

confidence: 99%

Section: Resultsmentioning

confidence: 99%

Re-evaluating currently available data and suggestions for planning randomised controlled studies regarding the use of hydroxyethyl starch in critically ill patients - a multidisciplinary statement

et al. 2013

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“…The optimal timing of RRT initiation still remains debatable owing to the contradictory reports in the literature. To our knowledge, the current systematic review is the first to exclusively include most RCTs to address the issue of the timing of RRT initiation and evaluate its impact on patient survival and RRT dependence (Table 2) [24–27, 41, 42]. …”

Section: Discussionmentioning

confidence: 99%

Earlier versus later initiation of renal replacement therapy among critically ill patients with acute kidney injury: a systematic review and meta-analysis of randomized controlled trials

Lai

Shiao

Wang

et al. 2017

Ann. Intensive Care

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BackgroundAlthough the optimal timing of initiation of renal replacement therapy (RRT) in critically ill patients with acute kidney injury has been extensively studied in the past, it is still unclear.MethodsIn this systematic review, we searched all related randomized controlled trials (RCTs) that directly compared earlier and later RRT published prior to June 25, 2016, from PubMed, MEDLINE, and EMBASE. We extracted the study characteristics and outcomes of all-cause mortality, RRT dependence, and intensive care unit (ICU) and hospital length of stay (LOS).ResultsWe identified 51 published relevant studies from 13,468 screened abstracts. Nine RCTs with 1627 participants were included in this meta-analysis. Earlier RRT was not associated with benefits in terms of mortality [relative risk (RR) 0.88, 95% confidence interval (CI) 0.68–1.14, p = 0.33] and RRT dependence (RR 0.81, 95% CI 0.46–1.42, p = 0.46). There were also no significant differences in the ICU and hospital LOS between patients who underwent earlier versus later RRT [standard means difference −0.08 (95% CI −0.26 to 0.09) and −0.11 (95% CI −0.37 to 0.16) day, respectively]. In subgroup analysis, earlier RRT was associated with a reduction in the in-hospital mortality among surgical patients (RR 0.78, 95% CI 0.64–0.96) and patients who underwent continuous renal replacement therapy (CRRT) (RR 0.80, 95% CI 0.67–0.96).ConclusionsCompared with later RRT, earlier initiation of RRT did not show beneficial impacts on patient outcomes. However, a lower rate of death was observed among surgical patients and in those who underwent CRRT. The included literature is highly heterogeneous and, therefore, potentially subject to bias. Further high-quality RCT studies are warranted.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-017-0265-6) contains supplementary material, which is available to authorized users.

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“…It is likely that double lumen catheters as low as 4 F will be sufficient to provide adequate flows for these machines [8]. Furthermore, and perhaps more importantly, large cohorts will be needed to determine which children and at what time points will benefit from CRRT, especially as growing evidence suggest that early initiation of CRRT improves outcomes in children [9] and adults [10]. Finally, we need more data to assess whether the approach of using a small CVVH circuit (to bridge patients until they are ready to receive PD catheters) could yield better outcomes than trying to use PD catheters when they are at greater risk of leaking.…”

Section: Discussionmentioning

confidence: 99%

Smaller circuits for smaller patients: improving renal support therapy with Aquadex™

et al. 2015

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Background Providing renal support for small children is very challenging using the machinery currently available in the United States. As the extra-corporeal volume (ECV) relative to blood volume increases, and the state of critical illness worsens, the chance for instability during continuous renal replacement therapy (CRRT) initiation rises. CRRT machines with smaller ECV could reduce the risks and improve outcomes. Methods 1) Case series of small children (n = 12) who received continuous veno-venous hemofiltration (CVVH) via Aquadex™ machine (ECV = 33 mL) with 30 mL/kg/h of pre-replacement fluids at Children’s of Alabama between December 2013 and April 2015. 2) In vitro assessment of fluid precision using the adapted CVVH system. Results We utilized 101 circuits over 261 days to provide CVVH for 12 children (median age = 30 days; median weight 3.4 kg). Median CVVH duration = 14.5 days (IQR = 10, 22.8 days). Most circuits were routinely stopped for change after 72 h. Only 5/101 (5 %) initiations were associated with mild transient change in vital signs. Complications were infrequent (three transient hypothermia; three puncture-site bleeding, one systemic bleeding, and one right atrial thrombus). Most patients (7/12, 58 %) were discharged from ICU, and 6/12 (50 %) were discharged home. Conclusions CRRT machines with low ECV can enable clinicians to provide adequate, timely, safe and efficient renal support to small critically ill infants.

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Timing of Initiation of Renal Replacement Therapy in Acute Kidney Injury: A Systematic Review and Meta-analysis

Cited by 48 publications

References 25 publications

Re-evaluating currently available data and suggestions for planning randomised controlled studies regarding the use of hydroxyethyl starch in critically ill patients - a multidisciplinary statement

Re-evaluating currently available data and suggestions for planning randomised controlled studies regarding the use of hydroxyethyl starch in critically ill patients - a multidisciplinary statement

Earlier versus later initiation of renal replacement therapy among critically ill patients with acute kidney injury: a systematic review and meta-analysis of randomized controlled trials

Smaller circuits for smaller patients: improving renal support therapy with Aquadex™

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