Early Renal Replacement Therapy Versus Standard Care in the ICU: A Systematic Review, Meta-Analysis, and Cost Analysis.
Renal replacement therapy (RRT) is the treatment of choice for severe acute kidney injury, but there are no firm guidelines as to the time of initiation of RRT in the critically ill. The primary objective of this study is to determine 1-month mortality rates of early versus late dialysis in critical care. As secondary end points, we provide a cost analysis of early versus late RRT initiation, intensive care unit (ICU) length of stay (LOS), hospital LOS, and number of patients on dialysis at day 60 postrandomization.
We identified all randomized controlled trials (RCTs) through EMLINE and MEDBASE that examined adult patients admitted to critical care who were randomized to receiving early dialysis versus standard of care.
Inclusion criteria: (1) RCTs conducted after the year 2000, (2) the population evaluated had to be adults admitted to ICU, (3) the intervention had to be early RRT versus standard care, and (4) outcomes had to measure patient mortality.
Two independent investigators reviewed search results and identified appropriate studies. Information was extracted using standardized case report forms.
Overall, 7 RCTs were included with a total of 1400 patients. Early RRT showed no survival benefit when compared to standard treatment (odds ratio [OR], 0.90 95% confidence interval [95% CI] 0.70-1.15, P = .39). There was no significant difference in length of hospital stay in patients with early RRT (-1.55 days [95% CI -4.75 to 1.65, P = .34]), in length of ICU stay (-0.79 days [95% CI -2.09 to 0.52], P = .24), or proportion of patients on dialysis at day 60 (OR 0.93 [95% CI 0.62 to 1.43], P = .79). Per patient, there is likely a small increase in costs (<US$1000) owing to increased total dialysis.
Across all measured domains, there is no clear benefit to early RRT. Moreover, this intervention may result in increased costs and exposes patients to an invasive therapy with potential harm.
1 Department of Internal Medicine, University of Ottawa, Ottawa, Ontario, Canada.
Dipayan
D
Chaudhuri
1 Department of Internal Medicine, University of Ottawa, Ottawa, Ontario, Canada.
Brent
B
Herritt
2 Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada.
Daren
D
Heyland
2 Department of Critical Care Medicine, Queen's University, Kingston, Ontario, Canada.
Louis-Philippe
LP
Gagnon
3 Ottawa Hospital Research Institute, Faculty of Medicine, University of Ottawa, Ontario, Canada.
Kednapa
K
Thavorn
1 Department of Internal Medicine, University of Ottawa, Ottawa, Ontario, Canada.
Daniel
D
Kobewka
4 Division of Critical Care, Department of Internal Medicine, University of Ottawa, The Ottawa Hospital General Campus, Ottawa, Ontario, Canada.
Kwadwo
K
Kyeremanteng
D058186:Acute Kidney Injury / Q000191:economics / Q000401:mortality / Q000628:therapy*; D002985:Clinical Protocols; D003365:Costs and Cost Analysis; D003422:Critical Care / Q000191:economics* / Q000379:methods; D017052:Hospital Mortality; D006801:Humans; D007362:Intensive Care Units / Q000191:economics*; D007902:Length of Stay / Q000191:economics; D016017:Odds Ratio; D016032:Randomized Controlled Trials as Topic; D017582:Renal Replacement Therapy / Q000191:economics*; D013997:Time Factors; D061665:Time-to-Treatment / Q000191:economics*; D016896:Treatment Outcome
cost analysis; early dialysis; systematic review