Department of Neurology, Geriatric Diseases Institute of Chengdu, Chengdu Fifth People's Hospital, Chengdu, China.
Eur Rev Med Pharmacol Sci. 2023 Jul;27(13):6046-6057. doi: 10.26355/eurrev_202307_32959.
The optimal time to start renal replacement therapy (RRT) for acute kidney injury (AKI) remains controversial. We aim to compare the effects of early vs. delayed RRT initiation on clinical outcomes in adult patients with AKI.
PubMed, Embase, Cochrane Library, Web of Science, Chinese Biomedical Literature Database, ClinicalTrials.gov, and the International Clinical Trial registry platform were systematically searched from inception to 7 August 2022. The review included randomized clinical trials (RCTs) comparing early and delayed initiation of RRT in AKI patients. The selected primary outcomes were short-term and long-term mortality. Secondary outcomes included RRT dependency, intensive care unit (ICU) length of stay, hospital length of stay, mechanical ventilator-free days, vasoactive agents-free days, RRT-free days, and adverse events.
Overall, 15 RCTs, including 5,625 patients, were analyzed. Early RRT showed no survival benefit when compared to the delayed therapy (28-or 30-day mortality: RR, 1.01, 95% CI: 0.94-1.08, p = 0.87; 60-day mortality: RR, 0.87, 95% CI: 0.71-1.06, p = 0.16; 90-day mortality: RR, 1.00, 95% CI: 0.88-1.13, p = 0.97; in-hospital mortality: RR, 1.05, 95% CI: 0.88-1.24, p = 0.58; ICU mortality: RR, 1.00, 95% CI: 0.91-1.10, p = 0.98). The delayed RRT did not lead to a higher risk of RRT dependency, ICU, or hospital length of stay than the early RRT. Similarly, early initiation of RRT did not lead to longer ventilator-free, vasoactive agent-free, and RRT-free days. However, early RRT initiation was associated with more adverse events.
Our study suggested that early RRT initiation was not associated with survival benefits or better clinical outcomes and increased the risk of RRT-associated adverse events. Current evidence does not support the use of early RRT for AKI patients without urgent indications.
急性肾损伤（AKI）患者开始肾脏替代治疗（RRT）的最佳时间仍存在争议。本研究旨在比较 AKI 患者早期与延迟 RRT 起始对临床结局的影响。
系统检索了 PubMed、Embase、Cochrane 图书馆、Web of Science、中国生物医学文献数据库、ClinicalTrials.gov 和国际临床试验注册平台，检索时间截至 2022 年 8 月 7 日。纳入比较 AKI 患者早期与延迟 RRT 起始的随机临床试验（RCT）。主要结局为短期和长期死亡率。次要结局包括 RRT 依赖性、重症监护病房（ICU）住院时间、医院住院时间、无机械通气天数、无血管活性药物天数、无 RRT 天数和不良事件。
共纳入 15 项 RCT，共计 5625 例患者。与延迟治疗相比，早期 RRT 并未显示出生存获益（28 或 30 天死亡率：RR，1.01，95%CI：0.94-1.08，p=0.87；60 天死亡率：RR，0.87，95%CI：0.71-1.06，p=0.16；90 天死亡率：RR，1.00，95%CI：0.88-1.13，p=0.97；院内死亡率：RR，1.05，95%CI：0.88-1.24，p=0.58；ICU 死亡率：RR，1.00，95%CI：0.91-1.10，p=0.98）。与早期 RRT 相比，延迟 RRT 并未导致 RRT 依赖性、ICU 或医院住院时间延长。同样，早期开始 RRT 并不能延长无呼吸机、无血管活性药物和无 RRT 天数。然而，早期 RRT 起始与更多的不良事件相关。
本研究表明，早期 RRT 起始与生存获益或更好的临床结局无关，并增加了与 RRT 相关的不良事件风险。目前的证据不支持对没有紧急指征的 AKI 患者使用早期 RRT。
