The efficacy of renal replacement therapy strategies for septic-acute kidney injury: A PRISMA-compliant network meta-analysis

Abstract

Background: Renal replacement therapy (RRT) is the main treatment for patients with sepsis-induced acute kidney injury (SAKI). However, the choice of RRT strategy remains controversial.

Objective: This study assessed the effectiveness of RRT variants in SAKI patients by a network meta-analysis.

Methods: This study searched the literature in the PubMed, EmBase, and Cochrane Library databases up to August 18, 2018. The outcomes of the analysis were the survival rate, renal recovery rate, intensive care unit (ICU) duration, and hospital duration.

Results: Twenty-two articles were included in the analysis. The results showed that only the negative control was inferior to the regimens of RRT with polymyxin B-immobilized fiber (PMXF), PMXF alone, continuous venovenous hemofiltration (CVVH), CVVH plus alkaline phosphatase (AP), continuous venovenous hemodialysis (CVVHD), high-volume CVVH, and extra high-volume CVVH in terms of the survival rate. According to the surface under the cumulative ranking , RRT with PMXF (84.4%) and PMXF (84.3%) were the treatments most likely to improve the survival rate among SAKI patients, followed by CVVH plus AP (69%). Continuous venovenous hemodiafiltration (CVVHDF), extra high-volume CVVHDF, intermittent venovenous hemodiafiltration (IVVHDF), and low-volume CVVHDF resulted in very similar survival rates. CVVH plus AP conferred relative advantages in the renal recovery rate and ICU duration.

Conclusion: CVVH, CVVHD, and their derived RRT strategies can improve survival rates in SAKI patients, but there is no significant difference among the RRT strategies. There was also no significant difference in the survival rate among CVVHDF, IVVHDF, and their derived strategies. More high-quality randomized controlled trials with large sample sizes are needed for further research.

Figure 1

Risk-of-bias graph of each included study. The assessments of each risk-of-bias item are presented for all included studies.

Figure 2

Network of the comparisons of the RRT strategies included in the analyses. (A) First part of the survival rate; (B) Second part of the survival rate; (C) Renal recovery rate; (D) ICU duration. In the network plot, the line between 2 interventions indicates a direct comparison, and the thickness indicates the precision of the direct estimate in each pairwise comparison. The nodes are weighted according to the number of studies. The abbreviation definitions are listed in Table 1. ICU = intensive care unit, RRT = renal replacement therapy.

Figure 3

Inconsistency plot of loop-specific heterogeneity for the survival rate result.

Figure 4

Comparison-adjusted funnel plot used to assess the first (A) and second parts of the survival rate results (B), renal recovery rate (C) and ICU duration results (D). ICU = intensive care unit.

Figure 5

Traditional analysis of the survival rate of the RRT strategies not included in the network analysis. RRT = renal replacement therapy.

Figure 6

Traditional analysis of the ICU duration of the RRT strategies not included in the network analysis. ICU = intensive care unit, RRT = renal replacement therapy.