Timing of renal replacement therapy initiation for acute kidney injury

Abstract

Background Acute kidney injury (AKI) is a common condition among patients in intensive care units (ICUs), and is associated with high death. Renal replacement therapy (RRT) is a blood purification technique used to treat the most severe forms of AKI. The optimal time to initiate RRT so as to improve clinical outcomes remains uncertain. This review complements another Cochrane review by the same authors: Intensity of continuous renal replacement therapy for acute kidney injury. Objectives To assess the effects of different timing (early and standard) of RRT initiation on death and recovery of kidney function in critically ill patients with AKI. Search methods We searched the Cochrane Kidney and Transplant's Specialised Register to 23 August 2018 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal and ClinicalTrials.gov. We also searched LILACS to 11 September 2017. Selection criteria We included all randomised controlled trials (RCTs). We included all patients with AKI in ICU regardless of age, comparing early versus standard RRT initiation. For safety and cost outcomes we planned to include cohort studies and non-RCTs. Data collection and analysis Data were extracted independently by two authors. The random-effects model was used and results were reported as risk ratios (RR) for dichotomous outcomes and mean differences (MD) for continuous outcomes, with 95% confidence intervals (CI).

Comparison between watchful waiting strategy and early initiation of renal replacement therapy in the critically ill acute kidney injury population: an updated systematic review and meta-analysis

“…Our present review did not demonstrate a statistically significant survival benefit of early RRT initiation, which is in line with the findings of most previous reviews [5][6][7][8][9][10]. Several studies that revealed positive [13] or negative [14,29,30] effects of early RRT initiation were not included in our meta-analysis.…”

“…Several recent meta-analyses examined the effect of early RRT initiation on patient survival and related outcomes [5][6][7][8][9][10][11]. All but one meta-analysis [11] reported that the early initiation of RRT did not provide a survival advantage (Additional file 1: Table S7).…”

“…Earlier retrospective and prospective studies revealed the survival benefits of early RRT initiation; however, since the AKIKI and ELAIN trials published in 2016, these survival benefits have become debatable. In recent years, several meta-analyses have been published, most of which investigated prospective or retrospective studies owing to the lack of large-scale randomized controlled trials (RCTs), and in these meta-analyses, a definitive conclusion regarding the optimal time of RRT initiation could not be drawn [5][6][7][8][9][10][11]. Conventional indications (refractory fluid overload, acidemia, hyperkalemia, and uremic complication) for RRT initiation are indisputable over several years.…”

Association between Prolonged Intermittent Renal Replacement Therapy and All-Cause Mortality in COVID-19 Patients Undergoing Invasive Mechanical Ventilation: a Retrospective Cohort Study

“…16 The relationship between CRRT and patients' outcome varied in patients with the different disease and was effected by the modalities, anticoagulation, vascular access management, timing of initiation and intensity of CRRT. 17,20,21 To date, no specific treatment has been confirmed to be effective for COVID-19, and supportive treatment remains essential. As far as we know, the effect of CRRT on critically ill patients with COVID-19 has not been reported.…”

Prescription of CRRT: a pathway to optimize therapy

“…The current evidence and KDIGO guideline support the implementation of CRRT in hemodynamically unstable patients and those with increased intracranial pressure [7]. Moreover, there is increasing evidence that CRRT is associated with a trend of short-and longterm dialysis independence [8][9][10][11]. However, there is no evidence demonstrating a mortality difference between all these modalities of RRT [8,10].…”