Timing of renal replacement therapy in patients with sepsis-associated acute kidney injury: A systematic review and meta-analysis

Abstract

Objective: The objective of this study was to evaluate the clinical efficacy of early and delayed renal replacement therapy (RRT) in patients with sepsis-associated acute kidney injury (AKI).

Methods: We searched three databases (PubMed, Web of Science, and Cochrane) for randomised controlled trials and cohort studies published up to March 28, 2022, and manually searched for relevant references. We included data from adults older than 18 years of age with sepsis-associated AKI. The Newcastle-Ottawa Scale and the Cochrane Risk of Bias tool were used for quality assessment. The primary outcome was 28-day mortality. Relative risk (RR), mean difference (MD), and 95% confidence interval (CI) were used for meta-analysis.

Results: There were a total of 3648 patients from four randomised controlled trials and eight cohort studies. The pooled results indicated that compared to delayed RRT, early RRT had a lower 28-day mortality (RR: 0.72; 95% CI: 0.59-0.88; P = 0.001; I² = 76%), and this result was robust according to sensitivity analysis, and no significant difference in 90-day mortality (RR: 0.80; 95% CI: 0.64-1.00; P = 0.05; I² = 82%),180-day mortality (RR: 1.07; 95% CI: 0.93-1.23; P = 0.36; I² = 0%), length of intensive care unit stay (MD - 0.94; 95% CI -2.43-0.55; P = 0.22; I² = 0%), length of hospital stay (MD - 1.02; 95% CI -4.21-2.17; P = 0.53; I² = 0%), and RRT dependence was found among survivors at 28 days (RR: 1.21; 95% CI: 0.73-2.00; P = 0.47; I² = 0%). Subgroup analysis of 28-day mortality showed that patients with sepsis-associated AKI who received early RRT at Kidney Disease: Improving Global Outcomes stage 2 or Sequential Organ Failure Assessment score ≤12 had a better chance of survival.

Conclusions: Early RRT may be beneficial to the 28-day short-term survival rate of patients with sepsis-associated AKI in Kidney Disease: Improving Global Outcomes stage 2 and having Sequential Organ Failure Assessment score less than or equal to 12 but has no significant effect on long-term survival, length of intensive care unit stay, the total length of hospital stay, and 28-day RRT dependence of survivors. These results still need to be confirmed by more large-scale randomised controlled studies.

Keywords: Acute kidney injury; Meta-analysis; Renal replacement therapy; Sepsis; Systematic review; Timing.