Early versus late initiation of renal replacement therapy in critically ill patients with acute kidney injury: a systematic review and meta-analysis

Abstract

Renal replacement therapy (RRT) is consensual in the presence of life-threatening complications associated with acute kidney injury (AKI). In the absence of urgent indications, the optimal timing for RRT initiation is still under debate. This systematic review and meta-analysis aims to compare early and late RRT initiation strategies in critically ill patients with AKI. The selected primary outcome was 28-day mortality. Secondary outcomes included overall mortality, recovery of renal function (RRF) and several RRT associated-adverse events. Studies were obtained from three databases (MEDLINE, CENTRAL and SCOPUS), searched from inception to September 2020.Thirteen randomized controlled trials (RCTs) were included, with 5193 patients in total. No significant difference was found between the two groups regarding 28-day mortality (Risk Ratio (RR) 1.00; 95% confidence interval (CI) 0.89 to 1.12; P = 1.00, I²=30%), overall mortality (RR 1.00; 95% CI 0.90 to 1.12; P = 0.98, I² = 42%) and RRF (RR 1.02, 95% CI 0.92 to 1.13, P = 0.75, I² =53%). However, early RRT initiation was associated with a significantly higher incidence of hypotensive (RR 1.34; 95% CI 1.17 to 1.53, P < 0.0001, I²=6%) and infectious events (RR 1.83; 95% CI 1.11 to 3.02, P = 0.02, I²=0%).In general, early RRT initiation does not seem to significantly improve the 28-day and overall mortality, neither the likelihood of RRF in critically ill patients with AKI. Moreover, it is associated with an increased risk for RRT-associated adverse events, namely hypotension and infection.