Skip to main content
SpringerLink
Log in

Timing of initiation of renal replacement therapy for acute kidney injury: a systematic review and meta-analysis of randomized-controlled trials

  • Original article
  • Published:
Clinical and Experimental Nephrology Aims and scope Submit manuscript

Abstract

Background

The effects of early renal replacement therapy (RRT) on mortality and renal recovery in patients with acute kidney injury (AKI) remain controversial. A systematic review and meta-analysis of randomized-controlled trials (RCTs) was performed.

Methods

MEDLINE, EMBASE and the Cochrane Library database (Cochrane Central Register of Controlled Trials) were searched to identify RCTs, investigating the effects of early RRT on patients with AKI.

Results

Six studies with a total of 1257 participants were included in this meta-analysis. Compared to late RRT, early RRT did not reduce the risk of mortality (RR 0.93, 95 % CI 0.68–1.26) or affect renal recovery (RR 0.88, 95 % CI 0.48–1.62) or composite endpoint (death or dialysis dependence) (RR 0.91, 95 % CI 0.71–1.17). There was no significant difference in adverse events in the analysis, between the early RRT and late RRT arms.

Conclusions

Early initiation of RRT for patients with AKI is not associated with decreased overall mortality or a delayed renal recovery rate. The optimal time to initiate RRT remains uncertain. Large scale and adequately powered RCTs are needed to detect the effects of early initiation of RRT in AKI patients.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Fig. 1
Fig. 2
Fig. 3
Fig. 4
Fig. 5

Similar content being viewed by others

References

  1. Ahlstrom A, Tallgren M, Peltonen S, et al. Survival and quality of life of patients requiring acute renal replacement therapy. Intensive Care Med. 2005;31:1222–8.

    Article  PubMed  Google Scholar 

  2. Uchino S, Kellum JA, Bellomo R, et al. Acute renal failure in critically ill patients: a multinational, multicenter study. JAMA. 2005;294:813–8.

    Article  CAS  PubMed  Google Scholar 

  3. Sugahara S, Suzuki H. Early start on continuous hemodialysis therapy improves survival rate in patients with acute renal failure following coronary bypass surgery. Hemodial Int. 2004;8:320–5.

    Article  PubMed  Google Scholar 

  4. Garcia-Fernandez N, Perez-Valdivieso JR, Bes-Rastrollo M, et al. Timing of renal replacement therapy after cardiac surgery: a retrospective multicenter Spanish cohort study. Blood Purif. 2011;32:104–11.

    Article  PubMed  Google Scholar 

  5. Moher D, Liberati A, Tetzlaff J, et al. Preferred reporting items for systematic reviews and meta-analyses: the PRISMA statement. Ann Intern Med. 2009;151(264–9):W64.

    Google Scholar 

  6. Ji Q, Mei Y, Wang X, et al. Timing of continuous veno-venous hemodialysis in the treatment of acute renal failure following cardiac surgery. Heart Vessels. 2011;26:183–9.

    Article  PubMed  Google Scholar 

  7. Wang X, Jie Yuan W. Timing of initiation of renal replacement therapy in acute kidney injury: a systematic review and meta-analysis. Ren Fail. 2012;34:396–402.

    Article  CAS  PubMed  Google Scholar 

  8. Liu Y, Davari-Farid S, Arora P, et al. Early versus late initiation of renal replacement therapy in critically ill patients with acute kidney injury after cardiac surgery: a systematic review and meta-analysis. J Cardiothorac Vasc Anesth. 2014;28:557–63.

    Article  PubMed  Google Scholar 

  9. Karvellas CJ, Farhat MR, Sajjad I, et al. A comparison of early versus late initiation of renal replacement therapy in critically ill patients with acute kidney injury: a systematic review and meta-analysis. Crit Care. 2011;15:R72.

    Article  PubMed  PubMed Central  Google Scholar 

  10. Bouman CS, Oudemans-Van Straaten HM, Tijssen JG, et al. Effects of early high-volume continuous venovenous hemofiltration on survival and recovery of renal function in intensive care patients with acute renal failure: a prospective, randomized trial. Crit Care Med. 2002;30:2205–11.

    Article  PubMed  Google Scholar 

  11. Chou YH, Huang TM, Wu VC, et al. Impact of timing of renal replacement therapy initiation on outcome of septic acute kidney injury. Crit Care. 2011;15:R134.

    Article  PubMed  PubMed Central  Google Scholar 

  12. Wierstra BT, Kadri S, Alomar S, et al. The impact of “early” versus “late” initiation of renal replacement therapy in critical care patients with acute kidney injury: a systematic review and evidence synthesis. Crit Care. 2016;20:122.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Gaudry S, Hajage D, Schortgen F, et al. Initiation strategies for renal-replacement therapy in the intensive care unit. N Engl J Med. 2016.

  14. Wald R, Adhikari NK, Smith OM, et al. Comparison of standard and accelerated initiation of renal replacement therapy in acute kidney injury. Kidney Int. 2015;88:897–904.

    Article  CAS  PubMed  Google Scholar 

  15. Zarbock A, Kellum JA, Schmidt C, et al. Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury: the ELAIN randomized clinical trial. JAMA. 2016;315:2190–9.

    Article  CAS  PubMed  Google Scholar 

  16. Higgins JPT, Green S. Cochrane handbook for systematic reviews of interventions version 5.1.0. Updated March 2011. Chichester: Wiley. 2011.

  17. Friedrich JO, Adhikari NK, Beyene J. Inclusion of zero total event trials in meta-analyses maintains analytic consistency and incorporates all available data. BMC Med Res Methodol. 2007;7:5.

    Article  PubMed  PubMed Central  Google Scholar 

  18. Borenstein M, Hedges LV, Higgins JP, et al. A basic introduction to fixed-effect and random-effects models for meta-analysis. Res Synth Methods. 2010;1:97–111.

    Article  PubMed  Google Scholar 

  19. DerSimonian R, Laird N. Meta-analysis in clinical trials. Control Clin Trials. 1986;7:177–88.

    Article  CAS  PubMed  Google Scholar 

  20. Higgins JP, Thompson SG, Deeks JJ, et al. Measuring inconsistency in meta-analyses. BMJ. 2003;327:557–60.

    Article  PubMed  PubMed Central  Google Scholar 

  21. Begg CB, Mazumdar M. Operating characteristics of a rank correlation test for publication bias. Biometrics. 1994;50:1088–101.

    Article  CAS  PubMed  Google Scholar 

  22. Egger M, Davey Smith G, Schneider M, et al. Bias in meta-analysis detected by a simple, graphical test. BMJ. 1997;315:629–34.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  23. Durmaz I, Yagdi T, Calkavur T, et al. Prophylactic dialysis in patients with renal dysfunction undergoing on-pump coronary artery bypass surgery. Ann Thorac Surg. 2003;75:859–64.

    Article  PubMed  Google Scholar 

  24. Pursnani ML, Hazra DK, Singh B, et al. Early haemodialysis in acute tubular necrosis. J Assoc Physicians India. 1997;45:850–2.

    CAS  PubMed  Google Scholar 

  25. Seabra VF, Balk EM, Liangos O, et al. Timing of renal replacement therapy initiation in acute renal failure: a meta-analysis. Am J Kidney Dis. 2008;52:272–84.

    Article  PubMed  Google Scholar 

  26. Payen D, Mateo J, Cavaillon JM, et al. Impact of continuous venovenous hemofiltration on organ failure during the early phase of severe sepsis: a randomized controlled trial. Crit Care Med. 2009;37:803–10.

    Article  PubMed  Google Scholar 

  27. Joannes-Boyau O, Honore PM, Perez P, et al. High-volume versus standard-volume haemofiltration for septic shock patients with acute kidney injury (IVOIRE study): a multicentre randomized controlled trial. Intensive Care Med. 2013;39:1535–46.

    Article  PubMed  Google Scholar 

  28. Conger JD. A controlled evaluation of prophylactic dialysis in post-traumatic acute renal failure. J Trauma. 1975;15:1056–63.

    Article  CAS  PubMed  Google Scholar 

  29. Crescenzi G, Torracca L, Pierri MD, et al. ‘Early’ and ‘late’ timing for renal replacement therapy in acute kidney injury after cardiac surgery: a prospective, interventional, controlled, single-centre trial. Interact CardioVasc Thorac Surg. 2015;20:616–21.

    Article  PubMed  Google Scholar 

  30. Jamale TE, Hase NK, Kulkarni M, et al. Earlier-start versus usual-start dialysis in patients with community-acquired acute kidney injury: a randomized controlled trial. Am J Kidney Dis. 2013;62:1116–21.

    Article  PubMed  Google Scholar 

  31. Smith OM, Wald R, Adhikari NK, et al. Standard versus accelerated initiation of renal replacement therapy in acute kidney injury (STARRT-AKI): study protocol for a randomized controlled trial. Trials. 2013;14:320.

    Article  PubMed  PubMed Central  Google Scholar 

  32. Euser AM, Zoccali C, Jager KJ, et al. Cohort studies: prospective versus retrospective. Nephron Clin Pract. 2009;113:c214–7.

    Article  PubMed  Google Scholar 

  33. Network VNARFT, Palevsky PM, Zhang JH, et al. Intensity of renal support in critically ill patients with acute kidney injury. N Engl J Med. 2008; 359:7–20.

  34. Palevsky PM. Dialysis modality and dosing strategy in acute renal failure. Semin Dial. 2006;19:165–70.

    Article  PubMed  Google Scholar 

  35. Palevsky PM, Liu KD, Brophy PD, et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for acute kidney injury. Am J Kidney Dis. 2013;61:649–72.

    Article  PubMed  Google Scholar 

  36. Thakar CV, Christianson A, Freyberg R, et al. Incidence and outcomes of acute kidney injury in intensive care units: a veterans administration study. Crit Care Med. 2009;37:2552–8.

    Article  PubMed  Google Scholar 

  37. Macedo E, Malhotra R, Bouchard J, et al. Oliguria is an early predictor of higher mortality in critically ill patients. Kidney Int. 2011;80:760–7.

    Article  CAS  PubMed  Google Scholar 

  38. Harris SK, Lewington AJ, Harrison DA, et al. Relationship between patients’ outcomes and the changes in serum creatinine and urine output and RIFLE classification in a large critical care cohort database. Kidney Int. 2015;88:369–77.

    Article  PubMed  Google Scholar 

  39. Seabra VF, Alobaidi S, Balk EM, et al. Off-pump coronary artery bypass surgery and acute kidney injury: a meta-analysis of randomized controlled trials. Clin J Am Soc Nephrol. 2010;5:1734–44.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Gettings LG, Reynolds HN, Scalea T. Outcome in post-traumatic acute renal failure when continuous renal replacement therapy is applied early vs. late. Intensive Care Med. 1999;25:805–13.

    Article  CAS  PubMed  Google Scholar 

  41. Shiao CC, Wu VC, Li WY, et al. Late initiation of renal replacement therapy is associated with worse outcomes in acute kidney injury after major abdominal surgery. Crit Care. 2009;13:R171.

    Article  PubMed  PubMed Central  Google Scholar 

  42. Chawla LS, Eggers PW, Star RA, et al. Acute kidney injury and chronic kidney disease as interconnected syndromes. N Engl J Med. 2014;371:58–66.

    Article  PubMed  Google Scholar 

  43. Hakim RM. Clinical implications of hemodialysis membrane biocompatibility. Kidney Int. 1993;44:484–94.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgments

This study was supported in part by Twelfth Five-Year Plan Medical Science Development Foundation of the Chinese People’s Liberation Army (AWS11J013) and the Army Medical Science Youth Development Project (13QNP088).

Author information

Author notes

    Authors and Affiliations

    1. Department of Nephrology, The 306th Hospital of Chinese PLA, 9 AnXiangBeiLi Road, Beijing, People’s Republic of China

      Yongxing Xu, Jianjun Gao, Bo Zhong, Yu Na & Jiamei Wei

    2. Clinical College of the 306th Hospital of Chinese PLA, AnHui Medical University, Hefei, People’s Republic of China

      Xinming Zheng

    Authors
    1. Yongxing Xu
      View author publications

      You can also search for this author in PubMed Google Scholar

    2. Jianjun Gao
      View author publications

      You can also search for this author in PubMed Google Scholar

    3. Xinming Zheng
      View author publications

      You can also search for this author in PubMed Google Scholar

    4. Bo Zhong
      View author publications

      You can also search for this author in PubMed Google Scholar

    5. Yu Na
      View author publications

      You can also search for this author in PubMed Google Scholar

    6. Jiamei Wei
      View author publications

      You can also search for this author in PubMed Google Scholar

    Corresponding author

    Correspondence to Yu Na.

    Ethics declarations

    All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. This article does not contain any studies with animals performed by any of the authors. Informed consent was not involved.

    Conflict of interest

    The authors have declared that no conflict of interest exists.

    Additional information

    Yongxing Xu and Jianjun Gao contributed equally to this work.

    About this article

    Check for updates. Verify currency and authenticity via CrossMark

    Cite this article

    Xu, Y., Gao, J., Zheng, X. et al. Timing of initiation of renal replacement therapy for acute kidney injury: a systematic review and meta-analysis of randomized-controlled trials. Clin Exp Nephrol 21, 552–562 (2017). https://doi.org/10.1007/s10157-016-1316-2

    Download citation

    • Received:

    • Accepted:

    • Published:

    • Issue Date:

    • DOI: https://doi.org/10.1007/s10157-016-1316-2

    Keywords

    Search

    Navigation