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

BackgroundAcute kidney injury is associated with high mortality, and is the most frequent complication encountered in patients residing in the intensive care unit. Although renal replacement therapy (RRT) is the standard of care for acute kidney injury, the optimal timing for initiation is still unknown.MethodsWe conducted a systemic review and meta-analysis of randomized controlled trials evaluating early versus late initiation of RRT in critically ill patients with acute kidney injury. We searched MEDLINE, Embase, and CENTRAL databases from inception to October 15, 2018. We screened studies and extracted data from published reported independently. The primary outcome was short-term mortality.ResultsA total of 2242 patients were included from 11 trials. No statistically significant effect was found for early versus late initiation of RRT on short-term mortality (risk ratio [RR] 0.99, 95% CI 0.84–1.17, p = 0.93) or long-term mortality (RR 0.98, 95% CI 0.85–1.13, p = 0.76). There were also no statistically significant effects on ICU length of stay, hospital length of stay, recovery of renal function, and renal replacement therapy dependence. Early initiation of RRT decreased the risk of metabolic acidosis (RR 0.65, 95% CI 0.43–0.99, p = 0.04), but increased the risk of hypotension (RR 1.24, 95% CI 1.08–1.43, p = 0.003).ConclusionsIn critically ill patients with acute kidney injury, early compared with late initiation of RRT is not associated with favorable mortality outcomes, although it appears to reduce the risk of metabolic acidosis.

背景：急性肾损伤（acute kidney injury）与高死亡率密切相关，是重症监护病房（intensive care unit, ICU）患者最常见的并发症。尽管肾替代治疗（renal replacement therapy, RRT）是急性肾损伤的标准治疗方案，但其启动的最佳时机至今尚未明确。
方法：本研究针对评估危重症急性肾损伤患者早期与晚期启动RRT疗效的随机对照试验，开展了系统评价与Meta分析。我们检索了建库至2018年10月15日的MEDLINE、Embase及CENTRAL数据库，由研究者独立筛选研究文献并提取发表数据。本研究的主要结局指标为短期死亡率。
结果：本研究共纳入11项试验的2242例患者。与晚期启动RRT相比，早期启动RRT对短期死亡率（风险比[risk ratio, RR] 0.99，95%置信区间[confidence interval, CI] 0.84–1.17，p = 0.93）及长期死亡率（RR 0.98，95%CI 0.85–1.13，p = 0.76）均未产生具有统计学意义的影响。此外，早期启动RRT对ICU住院时长、总住院时长、肾功能恢复及肾替代治疗依赖均无显著统计学差异。早期启动RRT可降低代谢性酸中毒的发生风险（RR 0.65，95%CI 0.43–0.99，p = 0.04），但会增加低血压的发生风险（RR 1.24，95%CI 1.08–1.43，p = 0.003）。
结论：在危重症急性肾损伤患者中，与晚期启动RRT相比，早期启动RRT并未带来更优的死亡率结局，尽管其似乎可降低代谢性酸中毒的发生风险。