Department of Intensive Care, Austin Hospital, Melbourne, VIC, Australia.
Department of Intensive Care, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
Crit Care Med. 2021 Aug 1;49(8):e781-e792. doi: 10.1097/CCM.0000000000005018.
The optimal time to initiate renal replacement therapy in critically ill patients with acute kidney injury is controversial. We investigated the effect of such earlier versus later initiation of renal replacement therapy on the primary outcome of 28-day mortality and other patient-centered secondary outcomes.
We searched MEDLINE (via PubMed), EMBASE, and Cochrane databases to July 17, 2020, and included randomized controlled trials comparing earlier versus later renal replacement therapy.
Multiple centers involved in eight trials.
Total of 4,588 trial participants.
Two independents investigators screened and extracted data using a predefined form. We selected randomized controlled trials in critically ill adult patients with acute kidney injury and compared of earlier versus later initiation of renal replacement therapy regardless of modality.
Overall, 28-day mortality was similar between earlier and later renal replacement therapy initiation (38.43% vs 38.06%, respectively; risk ratio, 1.01; [95% CI, 0.94-1.09]; I2 = 0%). Earlier renal replacement therapy, however, shortened hospital length of stay (mean difference, -2.14 d; [95% CI, -4.13 to -0.14]) and ICU length of stay (mean difference, -1.18 d; [95% CI, -1.95 to -0.42]). In contrast, later renal replacement therapy decreased the use of renal replacement therapy (relative risk, 0.69; [95% CI, 0.58-0.82]) and lowered the risk of catheter-related blood stream infection (risk ratio, 0.50, [95% CI, 0.29-0.86). Among survivors, renal replacement therapy dependence at day 28 was similar between earlier and later renal replacement therapy initiation (risk ratio, 0.98; [95% CI, 0.66-1.40]).
Earlier or later initiation of renal replacement therapy did not affect mortality. However, earlier renal replacement therapy was associated with significantly shorter ICU and hospital length of stay, whereas later renal replacement therapy was associated with decreased use of renal replacement therapy and decreased risk of catheter-related blood stream infection. These findings can be used to guide the management of critically ill patients with acute kidney injury.
在急性肾损伤的危重症患者中，开始肾脏替代治疗的最佳时机仍存在争议。本研究旨在评估早期与晚期开始肾脏替代治疗对 28 天死亡率及其他以患者为中心的次要结局的影响。
我们检索了 MEDLINE（通过 PubMed）、EMBASE 和 Cochrane 数据库，检索时间截至 2020 年 7 月 17 日，纳入了比较早期与晚期肾脏替代治疗的随机对照试验。
8 项试验涉及多个中心。
共 4588 例试验参与者。
两名独立的调查人员使用预定义的表格筛选和提取数据。我们选择了危重症合并急性肾损伤的成年患者的随机对照试验，并比较了早期与晚期开始肾脏替代治疗，无论采用何种治疗方式。
总体而言，早期与晚期肾脏替代治疗开始后 28 天死亡率无差异（分别为 38.43%和 38.06%，风险比为 1.01；[95%置信区间，0.94-1.09]；I2 = 0%）。然而，早期肾脏替代治疗可缩短住院时间（平均差值，-2.14 d；[95%置信区间，-4.13 至-0.14]）和 ICU 住院时间（平均差值，-1.18 d；[95%置信区间，-1.95 至-0.42]）。相反，晚期肾脏替代治疗可减少肾脏替代治疗的应用（相对风险，0.69；[95%置信区间，0.58-0.82]），降低导管相关血流感染的风险（风险比，0.50；[95%置信区间，0.29-0.86]）。在幸存者中，早期与晚期肾脏替代治疗开始后 28 天的肾脏替代治疗依赖率无差异（风险比，0.98；[95%置信区间，0.66-1.40]）。
早期或晚期开始肾脏替代治疗均不影响死亡率。然而，早期肾脏替代治疗与 ICU 和住院时间显著缩短相关，而晚期肾脏替代治疗与减少肾脏替代治疗的应用和降低导管相关血流感染的风险相关。这些发现可用于指导急性肾损伤危重症患者的管理。
