A comparison of early versus late initiation of renal replacement therapy in critically ill patients with acute kidney injury: a systematic review and meta-analysis
Constantine J. Karvellas,Maha R. Farhat,Imran Sajjad,Simon S Mogensen,Alexander A. Leung,Ron Wald,Sean M. Bagshaw +6 more
TLDR
Earlier institution of RRT in critically ill patients with AKI may have a beneficial impact on survival, however, this conclusion is based on heterogeneous studies of variable quality and only two randomised trials.Abstract:
Our aim was to investigate the impact of early versus late initiation of renal replacement therapy (RRT) on clinical outcomes in critically ill patients with acute kidney injury (AKI). Systematic review and meta-analysis were used in this study. PUBMED, EMBASE, SCOPUS, Web of Science and Cochrane Central Registry of Controlled Clinical Trials, and other sources were searched in July 2010. Eligible studies selected were cohort and randomised trials that assessed timing of initiation of RRT in critically ill adults with AKI. We identified 15 unique studies (2 randomised, 4 prospective cohort, 9 retrospective cohort) out of 1,494 citations. The overall methodological quality was low. Early, compared with late therapy, was associated with a significant improvement in 28-day mortality (odds ratio (OR) 0.45; 95% confidence interval (CI), 0.28 to 0.72). There was significant heterogeneity among the 15 pooled studies (I2 = 78%). In subgroup analyses, stratifying by patient population (surgical, n = 8 vs. mixed, n = 7) or study design (prospective, n = 10 vs. retrospective, n = 5), there was no impact on the overall summary estimate for mortality. Meta-regression controlling for illness severity (Acute Physiology And Chronic Health Evaluation II (APACHE II)), baseline creatinine and urea did not impact the overall summary estimate for mortality. Of studies reporting secondary outcomes, five studies (out of seven) reported greater renal recovery, seven (out of eight) studies showed decreased duration of RRT and five (out of six) studies showed decreased ICU length of stay in the early, compared with late, RRT group. Early RRT did not; however, significantly affect the odds of dialysis dependence beyond hospitalization (OR 0.62 0.34 to 1.13, I2 = 69.6%). Earlier institution of RRT in critically ill patients with AKI may have a beneficial impact on survival. However, this conclusion is based on heterogeneous studies of variable quality and only two randomised trials. In the absence of new evidence from suitably-designed randomised trials, a definitive treatment recommendation cannot be made.read more
Citations
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Journal ArticleDOI
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
Alexander Zarbock,John A. Kellum,Christoph Schmidt,Hugo Van Aken,Carola Wempe,Hermann Pavenstädt,Andreea Boanta,Joachim Gerß,Melanie Meersch +8 more
TL;DR: To determine whether early initiation of RRT in patients who are critically ill with AKI reduces 90-day all-cause mortality, a single-center randomized clinical trial of 231 critically ill patients with KDIGO stage 2 found that more patients in the early group recovered renal function by day 90.
Journal ArticleDOI
Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit
Stéphane Gaudry,David Hajage,Frédérique Schortgen,Laurent Martin-Lefevre,Bertrand Pons,Eric Boulet,Alexandre Boyer,Guillaume Chevrel,Nicolas Lerolle,Dorothée Carpentier,Nicolas de Prost,Alexandre Lautrette,Anne Bretagnol,Julien Mayaux,Saad Nseir,Bruno Mégarbane,Marina Thirion,Jean-Marie Forel,Julien Maizel,Hodane Yonis,Philippe Markowicz,Guillaume Thiery,Florence Tubach,Jean-Damien Ricard,Didier Dreyfuss +24 more
TL;DR: In a trial involving critically ill patients with severe acute kidney injury, a delayed strategy averted the need for renal-replacement therapy in an appreciable number of patients and found no significant difference with regard to mortality.
Journal ArticleDOI
Acute kidney injury: an increasing global concern
Norbert Lameire,Arvind Bagga,Dinna N. Cruz,Jan De Maeseneer,Zoltan H. Endre,John A. Kellum,Kathleen D. Liu,Ravindra L. Mehta,Neesh Pannu,Wim Van Biesen,Raymond Vanholder +10 more
TL;DR: Developing or progression of chronic kidney disease after one or more episode of acute kidney injury could have striking socioeconomic and public health outcomes for all countries.
Journal ArticleDOI
Acute kidney injury—epidemiology, outcomes and economics
Oleksa G. Rewa,Sean M. Bagshaw +1 more
TL;DR: Survivors of AKI, particularly those who remain on renal replacement therapy, often have reduced quality of life and consume substantially greater health-care resources than the general population as a result of longer hospitalizations, unplanned intensive care unit admissions and rehospitalizations.
Journal ArticleDOI
Acute kidney injury from sepsis: current concepts, epidemiology, pathophysiology, prevention and treatment.
TL;DR: More mechanistic studies are needed to better understand the convoluted pathophysiology of S-AKI and to translate these findings into potential treatment strategies and add to the promising pharmacologic approaches being developed and tested in clinical trials.
References
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Acute Renal Failure in Critically Ill Patients: A Multinational, Multicenter Study
Shigehiko Uchino,John A. Kellum,Rinaldo Bellomo,Gordon S. Doig,Hiroshi Morimatsu,Stanislao Morgera,Miet Schetz,Ian Tan,Catherine S. C. Bouman,Ettiene Macedo,Noel Gibney,Ashita Tolwani,Claudio Ronco +12 more
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