Skip to main content
Key Specialties
Cardiology Diabetology Endocrinology Gastroenterology Geriatrics and Gerontology Gynecology and Obstetrics Hematology Infectious Disease Internal Medicine Nephrology Neurology Oncology Pediatrics Respiratory Medicine Rheumatology Surgery
Congress Coverage
2024 ACC Congress 2023 ESMO Congress 2023 EASD Congress 2023 ERS Congress 2023 ESC Congress
Clinical Collections
Advances in Alzheimer’s

At a glance: The ONWARDS insulin icodec trials

A round-up of the ONWARDS phase 3 clinical trials evaluating the novel weekly insulin icodec in people with diabetes.
ADVANCED SEARCH
Log in
Top
Annals of Intensive Care
Published in: Annals of Intensive Care 1/2017

Open Access 01-12-2017 | Research

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

Authors: Tai-Shuan Lai, Chih-Chung Shiao, Jian-Jhong Wang, Chun-Te Huang, Pei-Chen Wu, Eric Chueh, Shih-Chieh Jeff Chueh, Kianoush Kashani, Vin-Cent Wu

Published in: Annals of Intensive Care | Issue 1/2017

Login to get access

Abstract

Background

Although 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.

Methods

In 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).

Results

We 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).

Conclusions

Compared 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.
Appendix
Available only for authorised users
Literature
1.
2.
Nisanevich V, Felsenstein I, Almogy G, Weissman C, Einav S, Matot I. Effect of intraoperative fluid management on outcome after intraabdominal surgery. Anesthesiology. 2005;103:25–32.CrossRefPubMed
3.
Clark E, Wald R, Walsh M, Bagshaw SM. Timing of initiation of renal replacement therapy for acute kidney injury: a survey of nephrologists and intensivists in Canada. Nephrol Dial Transpl. 2012;27:2761–7.CrossRef
4.
Balk RA. Severe sepsis and septic shock. Definitions, epidemiology, and clinical manifestations. Crit Care Clin. 2000;16:179–92.CrossRefPubMed
5.
Stein A, de Souza LV, Belettini CR, Menegazzo WR, Viégas Jú R, Costa Pereira EM, et al. Fluid overload and changes in serum creatinine after cardiac surgery: predictors of mortality and longer intensive care stay. A prospective cohort study. Crit Care. 2012;16:R99.CrossRefPubMedPubMedCentral
6.
Bagshaw SM, Laupland KB, Doig CJ, Mortis G, Fick GH, Mucenski M, et al. Prognosis for long-term survival and renal recovery in critically ill patients with severe acute renal failure: a population-based study. Crit Care. 2005;9:R700–9.CrossRefPubMedPubMedCentral
7.
Uchino S, Kellum JA, Bellomo R, Doig GS, Morimatsu H, Morgera S, et al. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA. 2005;294:813–8.CrossRefPubMed
8.
Manns B, Doig CJ, Lee H, Dean S, Tonelli M, Johnson D, et al. Cost of acute renal failure requiring dialysis in the intensive care unit: clinical and resource implications of renal recovery. Crit Care Med. 2003;31:449–55.CrossRefPubMed
9.
Pannu N, James M, Hemmelgarn B, Klarenbach S. Association between AKI, recovery of renal function, and long-term outcomes after hospital discharge. Clin J Am Soc Nephrol. 2013;8:194–202.CrossRefPubMed
10.
Wu VC, Shiao CC, Chang CH, Huang TM, Lai CF, Lin MC, et al. Long-term outcomes after dialysis-requiring acute kidney injury. Biomed Res Int. 2014;2014:365186.PubMedPubMedCentral
11.
Wu VC, Huang TM, Lai CF, Shiao CC, Lin YF, Chu TS, et al. Acute-on-chronic kidney injury at hospital discharge is associated with long-term dialysis and mortality. Kidney Int. 2011;80:1222–30.CrossRefPubMed
12.
Rondon-Berrios H, Palevsky PM. Treatment of acute kidney injury: an update on the management of renal replacement therapy. Curr Opin Nephrol Hypertens. 2007;16:64–70.CrossRefPubMed
13.
Schneider AG, Bellomo R, Bagshaw SM, Glassford NJ, Lo S, Jun M, et al. Choice of renal replacement therapy modality and dialysis dependence after acute kidney injury: a systematic review and meta-analysis. Intensive Care Med. 2013;39:987–97.CrossRefPubMed
14.
Akhoundi A, Singh B, Vela M, Chaudhary S, Monaghan M, Wilson GA, et al. Incidence of adverse events during continuous renal replacement therapy. Blood Purif. 2015;39:333–9.CrossRefPubMed
15.
Mehta RL, Pascual MT, Soroko S, Savage BR, Himmelfarb J, Ikizler TA, et al. Spectrum of acute renal failure in the intensive care unit: the PICARD experience. Kidney Int. 2004;66:1613–21.CrossRefPubMed
16.
Wald R, Bagshaw SM. The timing of renal replacement therapy initiation in acute kidney injury: is earlier truly better? Crit Care Med. 2014;42:1933–4.CrossRefPubMed
17.
Gibney N, Hoste E, Burdmann EA, Bunchman T, Kher V, Viswanathan R, et al. Timing of initiation and discontinuation of renal replacement therapy in AKI: unanswered key questions. Clin J Am Soc Nephrol. 2008;3:876–80.CrossRefPubMed
18.
Shingarev R, Wille K, Tolwani A. Management of complications in renal replacement therapy. Semin Dial. 2011;24:164–8.CrossRefPubMed
19.
Carl DE, Grossman C, Behnke M, Sessler CN, Gehr TWB. Effect of timing of dialysis on mortality in critically ill, septic patients with acute renal failure. Hemodial Int. 2010;14:11–7.CrossRefPubMed
20.
Wu VC, Ko WJ, Chang HW, Chen YS, Chen YW, Chen YM, et al. Early renal replacement therapy in patients with postoperative acute liver failure associated with acute renal failure: effect on postoperative outcomes. J Am Coll Surg. 2007;205:266–76.CrossRefPubMed
21.
Elahi MM, Lim MY, Joseph RN, Dhannapuneni RRV, Spyt TJ. Early hemofiltration improves survival in post-cardiotomy patients with acute renal failure. Eur J Cardiothorac Surg. 2004;26:1027–31.CrossRefPubMed
22.
Shiao CC, Ko WJ, Wu VC, Huang TM, Lai CF, Lin YF, et al. U-curve association between timing of renal replacement therapy initiation and in-hospital mortality in postoperative acute kidney injury. PLoS ONE. 2012;7:e42952.CrossRefPubMedPubMedCentral
23.
Shiao CC, Wu VC, Li WY, Lin YF, Hu FC, Young GH, et al. Late initiation of renal replacement therapy is associated with worse outcomes in acute kidney injury after major abdominal surgery. Crit Care. 2009;13:R171.CrossRefPubMedPubMedCentral
24.
Wierstra BT, Kadri S, Alomar S, Burbano X, Barrisford GW, Kao RLC. The impact of “early” versus “late” initiation of renal replacement therapy in critical care patients with acute kidney injury: a systematic review and evidence synthesis. Crit Care. 2016;20:122.CrossRefPubMedPubMedCentral
25.
Xu Y, Gao J, Zheng X, Zhong B, Na Y, Wei J (2016) Timing of initiation of renal replacement therapy for acute kidney injury: a systematic review and meta-analysis of randomized-controlled trials. Clin Exp Nephrol. [Epub ahead of print].
26.
Karvellas CJ, Farhat MR, Sajjad I, Mogensen SS, Leung AA, Wald R, et al. A comparison of early versus late initiation of renal replacement therapy in critically ill patients with acute kidney injury: a systemic review and meta-analysis. Crit Care. 2011;15:R72.CrossRefPubMedPubMedCentral
27.
Crews DC, Scialla JJ, Liu J, Guo H, Bandeen-Roche K, Ephraim PL, et al. Predialysis health, dialysis timing, and outcomes among older United States adults. J Am Soc Nephrol. 2014;25:370–9.CrossRefPubMed
28.
Gaudry S, Hajage D, Schortgen F, Martin-Lefevre L, Pons B, Boulet E, et al. Initiation strategies for renal-replacement therapy in the intensive care unit. N Eng J Med. 2016;375:122–33.CrossRef
29.
Zarbock A, Kellum JA, Schmidt C, Van Aken H, Wempe C, Pavenstädt H, et al. Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury: The ELAIN Randomized Clinical Trial. JAMA. 2016;315:2190–9.CrossRefPubMed
30.
Moher D, Liberati A, Tetzlaff J, Altman DG, Group P. Reprint–preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Phys Ther. 2009;89:873–80.PubMed
31.
32.
Juni P, Witschi A, Bloch R, Egger M. The hazards of scoring the quality of clinical trials for meta-analysis. JAMA. 1999;282:1054–60.CrossRefPubMed
33.
Sugahara S, Suzuki H. Early start on continuous hemodialysis therapy improves survival rate in patients with acute renal failure following coronary bypass surgery. Hemodial Int. 2004;8:320–5.CrossRefPubMed
34.
Koo JR, Yoon JW, Oh JE, Lee YK, Kim SG, Seo JW, et al. Prospective evaluation of early continuous venovenous hemofiltration (CVVH) on the outcome in patients with severe sepsis or septic shock. J Am Soc Nephrol. 2006;17:50A.
35.
Combes A, Brechot N, Amour J, Cozic N, Lebreton G, Guidon C, et al. Early high-volume hemofiltration versus standard care for post-cardiac surgery shock. The HEROICS Study. Am J Respir Crit Care Med. 2015;192:1179–90.CrossRefPubMed
36.
Wald R, Adhikari NK, Smith OM, Weir MA, Pope K, Cohen A, et al. Comparison of standard and accelerated initiation of renal replacement therapy in acute kidney injury. Kidney Int. 2015;88:897–904.CrossRefPubMed
37.
Jamale TE, Hase NK, Kulkarni M, Pradeep KJ, Keskar V, Jawale S, et al. Earlier-start versus usual-start dialysis in patients with community-acquired acute kidney injury: a randomized controlled trial. Am J Kidney Dis. 2013;62:1116–21.CrossRefPubMed
38.
Durmaz I, Yagdi T, Calkavur T, Mahmudov R, Apaydin AZ, Posacioglu H, et al. Prophylactic dialysis in patients with renal dysfunction undergoing on-pump coronary artery bypass surgery. Annals Thorac Surg. 2003;75:859–64.CrossRef
39.
VA/NIH ARFT Network, Palevsky PM, Zhang JH, O’Connor TZ, Chertow GM, Crowley ST, Choudhury D, et al. Intensity of renal support in critically ill patients with acute kidney injury. N Eng J Med. 2008;359:7–20.CrossRef
40.
Bagshaw SM, Berthiaume LR, Delaney A, Bellomo R. Continuous versus intermittent renal replacement therapy for critically ill patients with acute kidney injury: a meta-analysis. Crit Care Med. 2008;36:610–7.CrossRefPubMed
41.
Seabra VF, Balk EM, Liangos O, Sosa MA, Cendoroglo M, Jaber BL. Timing of renal replacement therapy initiation in acute renal failure: a meta-analysis. Am J Kidney Dis. 2008;52:272–84.CrossRefPubMed
42.
Wang X, Jie Yuan W. Timing of initiation of renal replacement therapy in acute kidney injury: a systematic review and meta-analysis. Ren Fail. 2012;34:396–402.CrossRefPubMed
43.
Mehta RL, McDonald B, Gabbai FB, Pahl M, Pascual MT, Farkas A, Kaplan RM. Collaborative Group for Treatment of ARFitICU. A randomized clinical trial of continuous versus intermittent dialysis for acute renal failure. Kidney Int. 2001;60:1154–63.CrossRefPubMed
44.
Kashani K, Mehta RL. We restrict CRRT to only the most hemodynamically unstable patients. Semin Dial. 2016;29:268–71.CrossRefPubMed
45.
Liu Y, Davari-Farid S, Arora P, Porhomayon J, Nader ND. Early versus late initiation of renal replacement therapy in critically ill patients with acute kidney injury after cardiac surgery: a systematic review and meta-analysis. J Cardiothorac Vasc Anesth. 2014;28:557–63.CrossRefPubMed
46.
Lowell JA, Schifferdecker C, Driscoll DF, Benotti PN, Bistrian BR. Postoperative fluid overload: not a benign problem. Crit Care Med. 1990;18:728–33.CrossRefPubMed
47.
Bagshaw SM, Uchino S, Bellomo R, Morimatsu H, Morgera S, Schetz M, et al. Timing of renal replacement therapy and clinical outcomes in critically ill patients with severe acute kidney injury. J Crit Care. 2009;24:129–40.CrossRefPubMed
48.
Smak Gregoor PJ, van Saase JL, vd Ingh HF, Weimar W, Kramer P. Disseminated histoplasmosis in a haemodialysis patient on immunosuppression after graft failure. Nephrol Dial Transpl. 1996;11:542–4.CrossRef
49.
Singbartl K, Kellum JA. AKI in the ICU: definition, epidemiology, risk stratification, and outcomes. Kidney Int. 2012;81:819–25.CrossRefPubMed
50.
Xu J, Shen B, Fang Y, Liu Z, Zou J, Liu L, et al. Postoperative fluid overload is a useful predictor of the short-term outcome of renal replacement therapy for acute kidney injury after cardiac surgery. Medicine. 2015;94:e1360.CrossRefPubMedPubMedCentral
51.
Bagshaw SM, Uchino S, Bellomo R, Morimatsu H, Morgera S, Schetz M, et al. Septic acute kidney injury in critically ill patients: clinical characteristics and outcomes. Clin J Am Soc Nephrol. 2007;2:431–9.CrossRefPubMed
52.
Payen D, Mateo J, Cavaillon JM, Fraisse F, Floriot C, Vicaut E, et al. Impact of continuous venovenous hemofiltration on organ failure during the early phase of severe sepsis: a randomized controlled trial. Crit Care Med. 2009;37:803–10.CrossRefPubMed
53.
Bouman CSC, Oudemans-Van Straaten HM, Tijssen JGP, Zandstra DF, Kesecioglu J. Effects of early high-volume continuous venovenous hemofiltration on survival and recovery of renal function in intensive care patients with acute renal failure: a prospective, randomized trial. Crit Care Med. 2002;30:2205–11.CrossRefPubMed
Metadata
Title
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
Authors
Tai-Shuan Lai
Chih-Chung Shiao
Jian-Jhong Wang
Chun-Te Huang
Pei-Chen Wu
Eric Chueh
Shih-Chieh Jeff Chueh
Kianoush Kashani
Vin-Cent Wu
Publication date
01-12-2017
Publisher
Springer Paris
Published in
Annals of Intensive Care / Issue 1/2017
Electronic ISSN: 2110-5820
DOI
https://doi.org/10.1186/s13613-017-0265-6

Other articles of this Issue 1/2017

Annals of Intensive Care 1/2017 Go to the issue

Review

Piperacillin–tazobactam as alternative to carbapenems for ICU patients

Research

Circulating bile acids predict outcome in critically ill patients

Research

Thrombomodulin favors leukocyte microvesicle fibrinolytic activity, reduces NETosis and prevents septic shock-induced coagulopathy in rats

Editorial

Shedding light on venoarterial PCO2 gradient

Review

Targeted temperature management in the ICU: guidelines from a French expert panel

Research

Red blood cell transfusion in the resuscitation of septic patients with hematological malignancies