Research
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
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* Corresponding author: Sean M Bagshaw bagshaw@ualberta.ca
1 Division of Critical Care Medicine, University of Alberta, 3C1.12 Walter C. Mackenzie Centre, 8440-122 Street, Edmonton, AB T6G2B7, Canada
2 Division of Pulmonary and Critical Care Medicine, Harvard Medical School, Brigham and Women's Hospital, 75 Francis Street, PBB - CA 3, Boston, MA 02115, USA
3 Department of Medicine, Renal Division, Brigham and Women's Hospital, 75 Francis Street, Boston, MA 02115, USA
4 Department of Anaesthesia, Hvidovre Hospital, DK-2650 Hvidovre, Copenhagen, Denmark
5 Department of Medicine, Division of General Internal Medicine, University of Calgary, 2500 University Dr. NW, Calgary, AB T2N 1N4, Canada
6 Division of Nephrology, Department of Medicine, St. Michael's Hospital, University of Toronto, 30 Bond Street, Toronto, ON M5B 1W8, Canada
Critical Care 2011, 15:R72 doi:10.1186/cc10061
Published: 25 February 2011Abstract
Introduction
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).
Methods
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.
Results
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%).
Conclusions
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.