Early versus late initiation of renal replacement therapy impacts mortality in septic patients with acute kidney injury: a meta-analysis

Background: Acute kidney injury (AKI) is a frequent complication in septic patients and increases in-hospital mortality. Our aim was to evaluate the impact of early versus late initiation of renal replacement therapy (RRT) on clinical outcomes in septic patients with acute kidney injury (AKI). Methods: Systematic review and meta-analysis were used in this study. We searched PubMed, EMBASE, MEDLINE and Cochrane Library. Results: Nine studies (two randomized controlled trials (RCTs) and seven retrospective cohorts) including 1694 patients were identified for detailed evaluation. This meta-analysis suggested that early RRT initiation within 48 hours (OR 0.30; 95% CI 0.20 to 0.45; I 2 0%) in septic patients with AKI reduced 28-day mortality (odds ratio (OR) 0.56; 95% confidence interval (CI) 0.37 to 0.86; I 2 73%), but intensive care unit (ICU) length of stay (LOS) (mean difference (MD) -1.49; 95% CI -3.65 to -0.67; I 2 53%), hospital LOS (MD -3.18; 95% CI -7.35 to 0.99; I 2 41%), the duration of RRT (MD -2.05; 95%CI -6.86 to 2.76; I 2 83%) and the duration of ventilation (MD 1.99; 95%CI -2.76 to 6.75; I 2 85%) were not influenced by the timing of RRT initiation. Conclusions: Early initiation of RRT within 48 hours in septic patients with AKI may have a beneficial impact on survival. However, this conclusion is based on heterogeneous trials of different quality and only two RCTs. Conclusive therapeutic recommendations regarding the optimal time to initiate RRT remain uncertain.