Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Meta-Analysis
. 2018 Dec 18:2018:6942829.
doi: 10.1155/2018/6942829. eCollection 2018.

Impact of Early versus Late Initiation of Renal Replacement Therapy in Patients with Cardiac Surgery-Associated Acute Kidney Injury: Meta-Analysis with Trial Sequential Analysis of Randomized Controlled Trials

Jie Cui  1 , Da Tang  2 , Zhen Chen  3 , Genglong Liu  4
Affiliations
Meta-Analysis

Impact of Early versus Late Initiation of Renal Replacement Therapy in Patients with Cardiac Surgery-Associated Acute Kidney Injury: Meta-Analysis with Trial Sequential Analysis of Randomized Controlled Trials

Jie Cui et al. Biomed Res Int. .

Abstract

Background: Previous studies have examined the effect of the initiation time of renal replacement therapy (RRT) in patients with cardiac surgery-associated acute kidney injury (CSA-AKI), but the findings remain controversial. The aim of this meta-analysis was to systematically and quantitatively compare the impact of early versus late initiation of RRT on the outcome of patients with CSA-AKI.

Methods: Four databases (PubMed, the Cochrane Library, ISI Web of Knowledge, and Embase) were systematically searched from inception to June 2018 for randomized clinical trials (RCTs). Two investigators independently performed the literature search, study selection, data extraction, and quality evaluation. Meta-analysis and trial sequential analysis (TSA) were used to examine the impact of RRT initiation time on all-cause mortality (primary outcome). The Grading of Recommendations Assessment Development and Evaluation (GRADE) was used to evaluate the level of evidence.

Results: We identified 4 RCTs with 355 patients that were eligible for inclusion. Pooled analyses indicated no difference in mortality for patients receiving early and late initiation of RRT (relative risk [RR] = 0.61, 95% confidence interval [CI] = 0.33 to 1.12). However, the results were not confirmed by TSA. Similarly, early RRT did not reduce the length of stay (LOS) in the intensive care unit (ICU) (mean difference [MD] = -1.04; 95% CI = -3.34 to 1.27) or the LOS in the hospital (MD = -1.57; 95% CI = -4.62 to 1.48). Analysis using GRADE indicated the certainty of the body of evidence was very low for a benefit from early initiation of RRT.

Conclusion: Early initiation of RRT had no beneficial impacts on outcomes in patients with CSA-AKI. Future larger and more adequately powered prospective RCTs are needed to verify the benefit of reduced mortality associated with early initiation of RRT.

Trial registration: This trial is registered with PROSPERO registration number CRD42018084465, registered on 11 February 2018.

PubMed Disclaimer

Figures

Figure 1
Figure 1
The flaw chart of included studies in the meta-analysis.
Figure 2
Figure 2
Forest plots of all 4 studies showed evidence of survival advantage of early renal replacement therapy initiation compared to late in analysis of mortality in patients with CSA-AKI.
Figure 3
Figure 3
Sensitivity analysis by excluding study by Sugahara et al.
Figure 4
Figure 4
Subgroup analysis-mean creatinine level, evaluating survival benefit of early renal replacement therapy initiation compared to late in analysis of mortality in patients with CSA-AKI.
Figure 5
Figure 5
Random-effects meta-regression analysis showing the relationship between the relative risk and publication year. The size of the circles is inversely proportional to the size of the result study variance, so that more precise studies have larger circles.
Figure 6
Figure 6
Assessment of publication bias using a funnel plot.
Figure 7
Figure 7
Trial sequential analysis for mortality in randomized controlled trials: a relative risk of 0.61, two-sided boundary, incidence of 42.6% in late RRT, incidence of 36.8% in early RRT, a low bias estimated relative risk reduction of 80%, α of 5%, and power of 80% were set. There is an estimated required information size (RIS) of 2162 randomized patients that are not reached. The boundaries for benefit are not crossed and no effect on mortality is observed; the Z-curve is parallel to the boundary of the early RRT.
Figure 8
Figure 8
Forest plot for ICU Length of stay and hospital Length of stay.
See this image and copyright information in PMC

References

    1. Hobson C. E., Yavas S., Segal M. S., et al. Acute kidney injury is associated with increased long-term mortality after cardiothoracic surgery. Circulation. 2009;119(18):2444–2453. doi: 10.1161/CIRCULATIONAHA.108.800011. - DOI - PubMed
    1. Wang Y., Bellomo R. Cardiac surgery-associated acute kidney injury: Risk factors, pathophysiology and treatment. Nature Reviews Nephrology. 2017;13(11):697–711. doi: 10.1038/nrneph.2017.119. - DOI - PubMed
    1. Mao H., Katz N., Ariyanon W., et al. Cardiac surgery-associated acute kidney injury. Cardiorenal Medicine. 2013;3(3):178–199. doi: 10.1159/000353134. - DOI - PMC - PubMed
    1. Haase M., Haase-Fielitz A., Plass M., et al. Prophylactic perioperative sodium bicarbonate to prevent acute kidney injury following open heart surgery: a multicenter double-blinded randomized controlled trial. PLoS Medicine. 2013;10(4) doi: 10.1371/journal.pmed.1001426.e1001426 - DOI - PMC - PubMed
    1. Xu J., Jiang W., Fang Y., Teng J., Ding X. Management of cardiac surgery-associated acute kidney injury. Contributions to Nephrology. 2016;187:131–142. doi: 10.1159/000443011. - DOI - PubMed