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

BACKGROUND: Acute 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. METHODS: We 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. RESULTS: A 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). CONCLUSIONS: In 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.