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Am J Kidney Dis. 2008 Aug;52(2):272-84. doi: 10.1053/j.ajkd.2008.02.371. Epub 2008 Jun 18.

Timing of renal replacement therapy initiation in acute renal failure: a meta-analysis.

Author information

1
Division of Nephrology, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil.

Abstract

BACKGROUND:

Some studies have suggested that early institution of renal replacement therapy (RRT) might be associated with improved outcomes in patients with acute renal failure (ARF).

STUDY DESIGN:

A systematic review and meta-analysis of randomized controlled trials and cohort comparative studies to assess the effect of early RRT on mortality in patients with ARF.

SETTING & POPULATION:

Hospitalized adult patients with ARF.

SELECTION CRITERIA FOR STUDIES:

We searched several databases for studies that compared the effect of "early" and "late" RRT initiation on mortality in patients with ARF. We included studies of various designs.

INTERVENTION:

Early RRT as defined in the individual studies.

OUTCOMES:

The primary outcome measure was the effect of early RRT on mortality stratified by study design. The pooled risk ratio (RR) for mortality was compiled using a random-effects model. Heterogeneity was evaluated by means of subgroup analysis and meta-regression.

RESULTS:

We identified 23 studies (5 randomized or quasi-randomized controlled trials, 1 prospective and 16 retrospective comparative cohort studies, and 1 single-arm study with a historic control group). By using meta-analysis of randomized trials, early RRT was associated with a nonsignificant 36% mortality risk reduction (RR, 0.64; 95% confidence interval, 0.40 to 1.05; P = 0.08). Conversely, in cohort studies, early RRT was associated with a statistically significant 28% mortality risk reduction (RR, 0.72; 95% confidence interval, 0.64 to 0.82; P < 0.001). The overall test for heterogeneity among cohort studies was significant (P = 0.005). Meta-regression yielded no significant associations; however, early dialysis therapy was associated more strongly with lower mortality in smaller studies (n < 100) by means of subgroup analysis.

LIMITATIONS:

Paucity of randomized controlled trials, use of variable definitions of early RRT, and publication bias preclude definitive conclusions.

CONCLUSION:

This hypothesis-generating meta-analysis suggests that early initiation of RRT in patients with ARF might be associated with improved survival, calling for an adequately powered randomized controlled trial to address this question.

PMID:
18562058
DOI:
10.1053/j.ajkd.2008.02.371
[Indexed for MEDLINE]

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