Background
Methods
Literature search
Study selection
Data extraction
Assessment of evidence quality and risk of bias
Definition of early versus late RRT initiation
Outcome measures
Primary outcome
Secondary outcomes
Statistical analysis
Results
Literature search
Study characteristics
Risk of bias
Primary outcomes
Secondary outcomes
Subgroup analysis
Outcome/subgroup | No. of studies | No. of events/no. of patients, early group | No. of events/no. of patients, late group | Pooled odds ratio (95% CI) | I2 (%) | P for subgroup difference |
---|---|---|---|---|---|---|
Population | 0.360 | |||||
Medical | 1 | 138/246 | 128/242 | 1.14 (0.80 to 1.63) | 0 | |
Surgical | 2 | 46/126 | 77/133 | 0.15 (0.01 to 2.62) | 85.9 | |
Mixed | 6 | 245/609 | 238/582 | 1.02 (0.80 to 1.30) | 0 | |
NGAL-based | 0.969 | |||||
No | 5 | 321/743 | 315/706 | 0.85 (0.49 to 1.47) | 75.1 | |
Yes | 4 | 108/238 | 128/251 | 0.84 (0.54 to 1.30) | 26.5 | |
Emergent need for RRT | 0.201 | |||||
Included | 3 | 22/104 | 30/70 | 0.32 (0.06 to 1.77) | 78.1 | |
Excluded | 6 | 407/877 | 413/887 | 1.00 (0.75 to 1.32) | 43 |
Outcome/subgroup | No. of studies | No. of patients | Pooled mean difference (95% CI) | I2 (%) | P for subgroup difference |
---|---|---|---|---|---|
ICU LOS | |||||
Population | 0.518 | ||||
Medical | 1 | 488 | 1.00 (− 0.91 to 2.91) | 0 | |
Surgical | 1 | 231 | − 0.50 (− 4.65 to 3.65) | 0 | |
Mixed | 4 | 943 | − 0.35 (− 1.77 to 1.08) | 0 | |
NGAL-based | 0.350 | ||||
No | 3 | 1213 | 0.30 (− 0.89 to 1.49) | 0 | |
Yes | 3 | 449 | − 1.20 (− 4.12 to 1.72) | 0 | |
Emergent need for RRT | 0.470 | ||||
Included | 1 | 106 | − 2.00 (− 7.78 to 3.78) | 0 | |
Excluded | 5 | 1556 | 0.17 (− 0.95 to 1.29) | 0 | |
MV days | |||||
Population | 0.054 | ||||
Medical | 1 | 488 | 1.00 (− 1.63 to 3.63) | 0 | |
Surgical | 1 | 231 | − 2.31 (− 4.50 to − 0.13) | 0 | |
Mixed | 4 | 883 | − 7.14 (− 15.05 to 0.76) | 89 | |
NGAL-based | 0.101 | ||||
No | 3 | 1213 | − 0.28 (− 2.01 to 1.45) | 0 | |
Yes | 3 | 389 | − 9.44 (− 20.25 to 1.38) | 92.2 | |
Emergent need for RRT | 0.269 | ||||
Included | 2 | 146 | − 13.28 (− 34.83 to 8.28) | 94.6 | |
Excluded | 4 | 1456 | − 1.09 (− 2.78 to 0.60) | 29.7 | |
RRT days | |||||
Population | 0.001 | ||||
Medical | 1 | 488 | 2.00 (1.21 to 2.79) | 0 | |
Surgical | 1 | 231 | − 16.00 (− 28.57 to − 3.43) | 0 | |
Mixed | 4 | 985 | − 5.19 (− 11.25 to 0.86) | 93 | |
NGAL-based | 0.031# | ||||
No | 3 | 1315 | 1.46 (0.21 to 2.71) | 60.4 | |
Yes | 3 | 389 | − 14.38 (− 28.74 to − 0.02) | 88.1 | |
Emergent need for RRT | < 0.001 | ||||
Included | 1 | 40 | − 24.50 (− 32.84 to − 16.16) | 0 | |
Excluded | 5 | 1664 | 0.45 (− 1.47 to 2.37) | 74.5 |
Sensitivity analysis
Trial, year | Jamale 2013 | STARRT-AKI pilot 2015 | ELAIN-2016 | AKIKI-2016 | IDEAL-ICU 2018 | The FST trial 2018 |
---|---|---|---|---|---|---|
Population, N | Mixed, 208 (only 3 surgical) | Mixed, 100 (56% sepsis) | Surgical, 231 | Mixed, 619 (80% medical) | Medical, 488 (septic shock) | Mixed, 118 (67% medical) |
Inclusion criteria | AKI Urea > 70 mg/dL or creatinine > 7 mg/dL | Severe AKI (any 2 criteria): (1) 2× increase Cr (2) UOP < 6 mL/kg/12 h (3) blood NGAL ≥ 400 ng/mL) | KDIGO stage 2 and plasma NGAL > 150 ng/mL and (any one): (1) Severe sepsis (2) Catecholamine (3) Refractory fluid overload (4) Non-renal organ failure, SOFA ≥ 2 | KDIGO stage 3 | RIFLE-F stage and septic shock within 48 h | AKI (KDIGO) and (1) Clinical diagnosis of ATN and (2) FST nonresponsive: urine output < 200 ml for 2 h |
NGAL level | NR | 400 ng/mL Median: > 1300 ng/mL | > 150 ng/mL Median 490 ng/mL (early) 618 ng/mL (late) | NR | NR | ≥ 150 ng/mL Median 625 ng/mL (early) 860 ng/mL (late) |
Other late criteria in addition to conventional indication | Nil | Nil | AKI progression (KDIGO stage 2 to 3) | AKI non-recovery (oliguria/anuria) > 72 h) | AKI non-recovery (UOP < 1000 in diuretics naive or < 2000 with diuretics) > 48 h | Nil |
Late group median from randomization to RRT (IQR), hours | NR | 31.57 (22.83–59.50) Mean and SD: 51.63 h (51.95) | 25.5 (18.8, 40.3) Mean and SD: 40.0 h (54.5) | 57 (28–53) | 51.5 (34.6–59.5) | 21 (16.75–48.5) |
Mortality (event/number) | 21/102 vs. 13/106 (90 days) | 18/48 vs. 19/52 (90 days) | 44/112 vs. 65/119 (90 days) | 150/311 vs. 153/308 (60 days) | 138/246 vs. 128/242 (60 days) | 36/58 vs. 35/60 (28 days) |