Intravascular administration of mannitol for acute kidney injury prevention: a systematic review and meta-analysis

Abstract

Background: The effects of mannitol administration on acute kidney injury (AKI) prevention remain uncertain, as the results from clinical studies were conflicting. Due to the lack of strong evidence, the KDIGO Guideline for AKI did not propose completely evidence-based recommendations on this issue.

Methods: We searched PubMed, EMBASE, clinicaltrials.gov and Cochrane Controlled Trials Register. Randomized controlled trials on adult patients at increased risk of AKI were considered on the condition that they compared the effects of intravascular administration of mannitol plus expansion of intravascular volume with expansion of intravascular volume alone. We calculated pooled risk ratios, numbers needed to treat and mean differences with 95% confidence intervals for dichotomous data and continuous data, respectively.

Results: Nine trials involving 626 patients were identified. Compared with expansion of intravascular volume alone, mannitol infusion for AKI prevention in high-risk patients can not reduce the serum creatinine level (MD 1.63, 95% CI -6.02 to 9.28). Subgroup analyses demonstrated that serum creatinine level is negatively affected by the use of mannitol in patients undergoing an injection of radiocontrast agents (MD 17.90, 95% CI 8.56 to 27.24). Mannitol administration may reduce the incidence of acute renal failure or the need of dialysis in recipients of renal transplantation (RR 0.34, 95% CI 0.21 to 0.57, NNT 3.03, 95% CI 2.17 to 5.00). But similar effects were not found in patients at high AKI risk, without receiving renal transplantation (RR 0.29, 95% CI 0.01 to 6.60).

Conclusions: Intravascular administration of mannitol does not convey additional beneficial effects beyond adequate hydration in the patients at increased risk of AKI. For contrast-induced nephropathy, the use of mannitol is even detrimental. Further research evaluating the efficiency of mannitol infusions in the recipients of renal allograft should be undertaken.

Figure 1. Flow diagram of literature search and study selection.

RCT, randomized controlled trial

Figure 2. Change of serum creatinine level among participants given mannitol versus control.

Note that Carcoana 2003 contain multiple but no shared intervention groups. We split it into two pairs of eligible comparisons (Carcoana 2003 com1 and Carcoana 2003 com2)

Figure 3. Risk of acute renal failure or need of dialysis intervention among participants given mannitol versus control.

Note that van Valenberg 1987 contains multiple but no shared intervention groups. We split it into two pairs of eligible comparisons (van Valenberg 1987 com1 and van Valenberg 1987 com2)

Figure 4,. Change of urine output among participants given mannitol versus control.

Note that Carcoana 2003 contains multiple but no shared intervention groups. We split it into two pairs of eligible comparisons (Carcoana 2003 com1 and Carcoana 2003 com2)