Timing of Renal Replacement Therapy Does Not Matter

Earlier initiation of renal replacement therapy (RRT) is not associated with improved outcomes vs later initiation of RRT among critically ill patients with acute kidney injury (AKI), according to a new analysis. However, a lower rate of mortality was observed in patients who had undergone surgery and in those who had received continuous RRT.

The ideal timing of initiation of RRT in critically ill patients with AKI has remained unclear despite extensive previous studies.
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For their analysis, the researchers identified 51 studies from 13,468 screened abstracts via searches of PubMed, MEDLINE, and EMBASE databases. A total of 1627 participants enrolled in 9 randomized controlled trials were included in the present analysis. All studies that met the inclusion criteria had directly compared earlier and later initiation of RRT and had been published prior to June 25, 2016.

Data on the characteristics and outcomes associated with all-cause mortality, RRT dependence, and intensive care unit (ICU) and hospital length of stay were extracted from each study.

Results indicated that earlier initiation of RRT had not been associated with benefits for mortality and RRT dependence. There were no significant differences in the ICU and hospital length of stay between patients who had received earlier RRT vs those who had received later RRT. However, subgroup analysis demonstrated that earlier RRT had been associated with decreased in-hospital mortality among patients who had undergone surgery and in patients who had received continuous RRT.

“Compared with later RRT, earlier initiation of RRT did not show beneficial impacts on patient outcomes,” the researchers concluded. “However, a lower rate of death was observed among surgical patients and in those who underwent [continuous RRT]. The included literature is highly heterogeneous and, therefore, potentially subject to bias. Further high-quality [randomized controlled trials] are warranted.”

—Christina Vogt

Reference:

Lai TS, Shiao CC, Wang JJ, et al. 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. Ann Intensive Care. 2017;7(1):38. https://doi.org/10.1186/s13613-017-0265-6.