Timing of Renal Replacement Therapy Initiation in the ICU

Increased morbidity and mortality are both associated with acute kidney injury in critically ill patients. The optimal timing of renal replacement therapy (RRT) is unclear and there are no guidelines to aid physicians in decision-making regarding timing of RRT. Researchers conducted a systematic review and meta-analysis to analyze and synthesize available evidence to guide clinical decisions for critically ill patients suffering from acute renal failure (ARF).

Results of a literature search and meta-analysis of randomized controlled trials that included mortality, length of stay in the hospital and in the intensive care unit yielded 13 trials that were included in the analysis.

The pooled estimates did not show a difference in mortality between early RRT versus late RRT (relative risk [RR], 1.01; 95% confidence interval [CI], 0.99-1.10). There was no significant difference in dialysis dependence at 90 days (RR, 0.77; 95% CI, 0.40-1.48).

In early versus late RRT initiation, early initiation was associated with a decrease in length of stay in the ICU (mean difference, 1.52 days; 95% CI, 0.6-2.44; P=0.001) and in hospital stay (mean difference, 6.26 days; 95% CI, 4.97-7.56; P<0.001). There was an association between early RRT initiation and decreased hyperkalemia (RR, 0.57; 95% CI, 0.34-0.97; P=.04) and respiratory complications (RR, 0.86; 95% CI, 0.77-0.97; P=0.01).

“Early initiation of RRT in ARF in critically ill patients does not seem to alter mortality or the dependence on long-term dialysis. However, it does shorten the ICU and hospital length of stay, and is associated with decreased hyperkalemia and respiratory complications,” the researchers said.

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Source: Kalot M, Aljabiri Y, Chaudhyr S, Husainat N, Bhargava R, Mustafa R. Timing of initiation of renal replacement therapy in critically ill patients with AKI: A systematic review and meta-analysis. Abstract of a poster presented at the American Society of Nephrology Kidney Week 2019 (Abstract FR-PO060), November 8, 2019, Washington, DC.