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Critical Care
Published in: Critical Care 1/2016

Open Access 01-12-2016 | Research

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

Authors: Benjamin T. Wierstra, Sameer Kadri, Soha Alomar, Ximena Burbano, Glen W. Barrisford, Raymond L. C. Kao

Published in: Critical Care | Issue 1/2016

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Abstract

Background

The optimal timing of initiating renal replacement therapy (RRT) in critical illness complicated by acute kidney injury (AKI) is not clearly established. Trials completed on this topic have been marked by contradictory findings as well as quality and heterogeneity issues. Our goal was to perform a synthesis of the evidence regarding the impact of “early” versus “late” RRT in critically ill patients with AKI, focusing on the highest-quality research on this topic.

Methods

A literature search using the PubMed and Embase databases was completed to identify studies involving critically ill adult patients with AKI who received hemodialysis according to “early” versus “late”/“standard” criteria. The highest-quality studies were selected for meta-analysis. The primary outcome of interest was mortality at 1 month (composite of 28- and 30-day mortality). Secondary outcomes evaluated included intensive care unit (ICU) and hospital length of stay (LOS).

Results

Thirty-six studies (seven randomized controlled trials, ten prospective cohorts, and nineteen retrospective cohorts) were identified for detailed evaluation. Nine studies involving 1042 patients were considered to be of high quality and were included for quantitative analysis. No survival advantage was found with “early” RRT among high-quality studies with an OR of 0.665 (95 % CI 0.384–1.153, p = 0.146). Subgroup analysis by reason for ICU admission (surgical/medical) or definition of “early” (time/biochemical) showed no evidence of survival advantage. No significant differences were observed in ICU or hospital LOS among high-quality studies.

Conclusions

Our conclusion based on this evidence synthesis is that “early” initiation of RRT in critical illness complicated by AKI does not improve patient survival or confer reductions in ICU or hospital LOS.
Appendix
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Metadata
Title
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
Authors
Benjamin T. Wierstra
Sameer Kadri
Soha Alomar
Ximena Burbano
Glen W. Barrisford
Raymond L. C. Kao
Publication date
01-12-2016
Publisher
BioMed Central
Published in
Critical Care / Issue 1/2016
Electronic ISSN: 1364-8535
DOI
https://doi.org/10.1186/s13054-016-1291-8

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