Early versus late initiation of renal replacement therapy in patients with acute kidney injury-a systematic review & meta-analysis of randomized controlled trials.
Early versus late initiation of renal replacement therapy in patients with acute kidney injury-a systematic review & meta-analysis of randomized controlled trials.
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DOI：
10.1186/s12882-017-0486-9
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发表时间：
2017-02-28
期刊：
影响因子：
2.3
通讯作者：
Das RR
中科院分区：
文献类型：
--
作者：
Bhatt GC;Das RR
急性肾损伤(AKI)是危重病患者常见的并发症，其发病率和死亡率均较高。严重的AKI可能与高达60%的住院死亡率有关。多年来，肾脏替代疗法(RRT)已成为AKI治疗的主要手段。然而，根据随机对照试验的相互矛盾的数据，为了改善患者结果而开始RRT的确切时间仍然存在争议。因此，进行了一项系统的综述和荟萃分析，以评估“早期”与“晚期”启动RRT的影响。通过检索主要数据库Medline/Pubmed、Embase和Google Scholar，检索1970-2016年间已发表的所有文献。对这些文章的参考文献列表进行了审查，以确定其他相关文章。作者对检索到的关于“早期/预防性”RRT与“晚期/AS和当需要时”RRT的效果的论文进行了审查，并使用标准化的数据收集工具提取数据。比较早期RRT或预防性RRT与晚期或AS以及何时需要RRT的随机试验(RCT)。主要结果是第90天的所有原因死亡率和透析依赖性。次要观察指标为：ICU住院时间、住院时间、肾功能恢复情况和不良事件。在检索到的547条引文中，对44篇文章的全文进行了资格评估。其中包括10项随机对照试验，1,636名参与者。所有试验均为开放标签，6项试验对分配隐瞒的偏倚不明确或风险较高，4项试验对分配隐瞒的偏向风险较低。在不同的研究中，对早期和晚期的定义是不同的。因此，早期或晚期的定义是根据个体研究的定义而定的。与晚期RRT相比，早期RRT在第30天的死亡率[6项研究；1301名参与者；RR，0.92；95%CI：0.76，1.12]；第60天的死亡率[3项试验；1075名参与者；RR，0.94；95%CI：0.78，1.14]；第90天的死亡率[3项试验；555名参与者；RR，0.94；95%CI：0.67，1.33]；总的ICU或医院死亡率；第90天的透析依赖性[3项试验；(RR，1.06；95%可信区间：0.53，2.12)]。ICU天数、住院天数、肾功能恢复情况无明显差异。基于RRT或内外科混合治疗方式与手术治疗方式或基于疾病严重程度的亚组分析显示，在结果测量方面没有差异。分配隐藏风险高或不明确的试验显示早期RRT有好处(RR，0.74；95%CI：0.59，0.91)，而分配隐藏风险低的试验死亡率无差异(RR，1.02；95%CI：0.89，1.17)。大多数结果所产生的等级证据都是“低质量”的。这项最新的荟萃分析显示，对于AKI患者，早期开始RRT并没有额外的好处。所产生的等级证据“质量不高”，纳入的试验中存在高度的异质性。CRD42016043092。本文的在线版本(doi：10.1186/s12882-0170486-9)包含补充材料，授权用户可以使用。
Acute kidney injury (AKI) is a common complication in the critically ill patients and associated with a substantial morbidity and mortality. Severe AKI may be associated with up to 60% hospital mortality. Over the years, renal replacement therapy (RRT) has emerged as the mainstay of the treatment for AKI. However, the exact timing of initiation of RRT for better patient outcome is still debatable with conflicting data from randomized controlled trials. Thus, a systematic review and meta-analysis was performed to assess the impact of “early” versus “late” initiation of RRT. All the published literature through the major databases including Medline/Pubmed, Embase, and Google Scholar were searched from 1970 to October 2016. Reference lists from the articles were reviewed to identify additional pertinent articles. Retrieved papers concerning the effect of “early/prophylactic” RRT versus “late/as and when required” RRT were reviewed by the authors, and the data were extracted using a standardized data collection tool. Randomized trials (RCTs) comparing early initiation of RRT or prophylactic RRT with late or as and when required RRT were included. The primary outcome measures were all cause mortality and dialysis dependence on day 90. The secondary outcome measures were: length of ICU stay, length of hospital stay, recovery of renal function and adverse events. Of the 547 citation retrieved, full text of 44 articles was assessed for eligibility. Of these a total of 10 RCTs with 1,636 participants were included. All the trials were open label; six trials have unclear or high risk of bias for allocation concealment while four trials have low risk of bias for allocation concealment. There was a variable definition of early versus late in different studies. Thus, the definition of early or late was taken according to individual study definition. Compared to late RRT, there was no significant benefit of early RRT on day 30 mortality [6 studies; 1301 participants; RR, 0.92;95% CI: 0.76, 1.12); day 60 mortality [3 trials;1075 participants; RR, 0.94; 95% CI: 0.78, 1.14)]; day 90 mortality [3 trials; 555 participants; RR,0.94;95% CI: 0.67, 1.33)]; overall ICU or hospital mortality; dialysis dependence on day 90 [3 trials; (RR, 1.06; 95% CI:0.53, 2.12)]. There was no significant difference between length of ICU or hospital stay or recovery of renal functions. A subgroup analysis based on modality of RRT or mixed medical and surgical vs. surgical or based on severity of illness showed no difference in outcome measure. The trials with high or unclear risk of bias for allocation concealment showed benefit of early RRT (RR, 0.74; 95% CI: 0.59, 0.91) while the trials with low risk of bias for allocation concealment showed no difference in the mortality (RR, 1.02; 95% CI: 0.89, 1.17). Grade evidence generated for most of the outcomes was “low quality”. This updated meta-analysis showed no added benefit of early initiation of RRT for patients with AKI. The grade evidence generated was of “low quality” and there was a high heterogeneity in the included trials. CRD42016043092. The online version of this article (doi:10.1186/s12882-017-0486-9) contains supplementary material, which is available to authorized users.