Heng-Chih Pan1,2,3,4, Ying-Ying Chen2,5, I-Jung Tsai6, Chih-Chung Shiao7, Tao-Min Huang8, Chieh-Kai Chan9, Hung-Wei Liao10, Tai-Shuan Lai8, Yvonne Chueh11, Vin-Cent Wu12,13, Yung-Ming Chen2,8. 1. Division of Nephrology, Department of Internal Medicine, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan. 2. Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan. 3. Chang Gung University College of Medicine, Taoyuan, Taiwan. 4. Community Medicine Research Center, Keelung Chang Gung Memorial Hospital, Keelung, Taiwan. 5. Division of Nephrology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan. 6. Division of Nephrology, Department of Pediatrics, National Taiwan University Children's Hospital, Taipei, Taiwan. 7. Division of Nephrology, Department of Internal Medicine, Saint Mary's Hospital Luodong, Yilan, Taiwan. 8. Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, 7 Chung-Shan South Road, Taipei, Taiwan. 9. Department of Internal Medicine, National Taiwan University Hospital, Hsin-Chu Branch, Hsin Chu County, Taiwan. 10. Chinru Clinic, Taipei, Taiwan. 11. Department of Family Medicine, Cleveland Clinic Akron General Hospital, Akron, OH, USA. 12. Department of Internal Medicine, National Taiwan University Hospital, College of Medicine, National Taiwan University, 7 Chung-Shan South Road, Taipei, Taiwan. q91421028@ntu.edu.tw. 13. National Taiwan University Hospital Study Group of ARF (NSARF), Taiwan Consortium for Acute Kidney Injury and Renal Diseases (CAKS, TCTC), Taipei, Taiwan. q91421028@ntu.edu.tw.
Abstract
BACKGROUND: Acute kidney injury (AKI) is a common yet possibly fatal complication among critically ill patients in intensive care units (ICU). Although renal replacement therapy (RRT) is an important supportive management for severe AKI patients, the optimal timing of RRT initiation for these patients is still unclear. METHODS: In this systematic review, we searched all relevant randomized controlled trials (RCTs) that directly compared accelerated with standard initiation of RRT from PUBMED, MEDLINE, EMBASE, and Cnki.net published prior to July, 20, 2020. We extracted study characteristics and outcomes of being free of dialysis, dialysis dependence and mortality. We rated the certainty of evidence according to Cochrane methods and the GRADE approach. RESULTS: We identified 56 published relevant studies from 1071 screened abstracts. Ten RCTs with 4753 critically ill AKI patients in intensive care unit (ICU) were included in this meta-analysis. In our study, accelerated and standard RRT group were not associated with all-cause mortality (log odds-ratio [OR]: - 0.04, 95% confidence intervals [CI] - 0.16 to 0.07, p = 0.46) and free of dialysis (log OR: - 0.03, 95% CI - 0.14 to 0.09, p = 0.65). In the subgroup analyses, accelerated RRT group was significantly associated with lower risk of all-cause mortality in the surgical ICU and for those who received continuous renal replacement therapy (CRRT). In addition, patients in these two subgroups had higher chances of being eventually dialysis-free. However, accelerated initiation of RRT augmented the risk of dialysis dependence in the subgroups of patients treated with non-CRRT modality and whose Sequential Organ Failure Assessment (SOFA) score were more than 11. CONCLUSIONS: In this meta-analysis, critically ill patients with severe AKI would benefit from accelerated RRT initiation regarding all-cause mortality and being eventually free of dialysis only if they were surgical ICU patients or if they underwent CRRT treatment. However, the risk of dialysis dependence was increased in the accelerated RRT group when those patients used non-CRRT modality or had high SOFA scores. All the literatures reviewed in this study were highly heterogeneous and potentially subject to biases. Trial registration CRD42020201466, Sep 07, 2020. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=201466 .
BACKGROUND:Acute kidney injury (AKI) is a common yet possibly fatal complication among critically illpatients in intensive care units (ICU). Although renal replacement therapy (RRT) is an important supportive management for severe AKI patients, the optimal timing of RRT initiation for these patients is still unclear. METHODS: In this systematic review, we searched all relevant randomized controlled trials (RCTs) that directly compared accelerated with standard initiation of RRT from PUBMED, MEDLINE, EMBASE, and Cnki.net published prior to July, 20, 2020. We extracted study characteristics and outcomes of being free of dialysis, dialysis dependence and mortality. We rated the certainty of evidence according to Cochrane methods and the GRADE approach. RESULTS: We identified 56 published relevant studies from 1071 screened abstracts. Ten RCTs with 4753 critically ill AKIpatients in intensive care unit (ICU) were included in this meta-analysis. In our study, accelerated and standard RRT group were not associated with all-cause mortality (log odds-ratio [OR]: - 0.04, 95% confidence intervals [CI] - 0.16 to 0.07, p = 0.46) and free of dialysis (log OR: - 0.03, 95% CI - 0.14 to 0.09, p = 0.65). In the subgroup analyses, accelerated RRT group was significantly associated with lower risk of all-cause mortality in the surgical ICU and for those who received continuous renal replacement therapy (CRRT). In addition, patients in these two subgroups had higher chances of being eventually dialysis-free. However, accelerated initiation of RRT augmented the risk of dialysis dependence in the subgroups of patients treated with non-CRRT modality and whose Sequential Organ Failure Assessment (SOFA) score were more than 11. CONCLUSIONS: In this meta-analysis, critically illpatients with severe AKI would benefit from accelerated RRT initiation regarding all-cause mortality and being eventually free of dialysis only if they were surgical ICU patients or if they underwent CRRT treatment. However, the risk of dialysis dependence was increased in the accelerated RRT group when those patients used non-CRRT modality or had high SOFA scores. All the literatures reviewed in this study were highly heterogeneous and potentially subject to biases. Trial registration CRD42020201466, Sep 07, 2020. https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=201466 .
Entities:
Keywords:
Accelerated dialysis; Dialysis dependence; Free of dialysis; Mortality; Renal replacement therapy; Standard dialysis
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