Intensity of continuous renal replacement therapy for acute kidney injury

Alicia I Fayad; Daniel G Buamscha; Agustín Ciapponi

doi:10.1002/14651858.CD010613.pub2

Cochrane Database of Systematic Reviews

Intensidad de la terapia de reemplazo renal continua para la insuficiencia renal aguda

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DOI:

https://doi.org/10.1002/14651858.CD010613.pub2 Copy DOI

Database:

Cochrane Database of Systematic Reviews

Version published:

04 October 2016see what's new

Type:

Intervention

Stage:

Review

Cochrane Editorial Group:

Cochrane Kidney and Transplant Group

Copyright:

Copyright © 2016 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

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Authors

Alicia I Fayad

Correspondence to: Pediatric Nephrology, Ricardo Gutierrez Children's Hospital, Buenos Aires, Argentina

[email protected]

[email protected]
Daniel G Buamscha

Pediatric Critical Care Unit, Juan Garrahan Children's Hospital, Buenos Aires, Argentina
Agustín Ciapponi

Argentine Cochrane Centre, Institute for Clinical Effectiveness and Health Policy (IECS‐CONICET), Buenos Aires, Argentina

Contributions of authors

Draft the protocol: AF, DB, AC
Study selection: AF, DB
Extract data from studies: AF, DB
Enter data into RevMan: AF
Carry out the analysis: AF, AC
Interpret the analysis: AF, DB, AC
Draft the final review: AF, DB, AC
Disagreement resolution: AC
Update the review: AF

Sources of support

Internal sources

No sources of support supplied, Other.

External sources

No sources of support supplied

Declarations of interest

Alicia I Fayad: none known
Daniel G Buamscha: none known
Agustín Ciapponi: none known

Acknowledgements

The authors wish to thank the referees for their advice and feedback during the preparation of this review.

The authors would also like to thank all study authors who provided additional information about their studies and Daniel Comande, Librarian of the Institute for Clinical Effectiveness and Health Policy (Argentina) for his help in search for the literature.

We would like to thank Ms Narelle Willis and Ms Gail Higgins from Cochrane Kidney and Transplant for their help with this review and especially to Marta Roque Figuls, Iberoamerican Cochrane Centre for her support and editorial advice during the preparation of this systematic review.

Version history

Published

Title

Stage

Authors

Version

2016 Oct 04

Intensity of continuous renal replacement therapy for acute kidney injury

Review

Alicia I Fayad, Daniel G Buamscha, Agustín Ciapponi

https://doi.org/10.1002/14651858.CD010613.pub2

2013 Jun 24

Intensity of continuous renal replacement therapy for acute kidney injury

Protocol

Alicia I Fayad, Daniel G Buamscha, Agustín Ciapponi

https://doi.org/10.1002/14651858.CD010613

Differences between protocol and review

We modified the definitions of intensive and less intensive CRRT according to suggestions of the Editorial Committee and external referees.

'Summary of findings' tables have been incorporated.

Keywords

MeSH

Medical Subject Headings (MeSH) Keywords

Medical Subject Headings Check Words

Humans;

PICOs

Population

Intervention

Comparison

Outcome

The PICO model is widely used and taught in evidence-based health care as a strategy for formulating questions and search strategies and for characterizing clinical studies or meta-analyses. PICO stands for four different potential components of a clinical question: Patient, Population or Problem; Intervention; Comparison; Outcome.

See more on using PICO in the Cochrane Handbook.

Figure 1

Study flow diagram

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Figure 2

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies

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Figure 3

Risk of bias summary: review authors' judgements about each risk of bias item for each included study

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Figure 4

Funnel plot of comparison: 1 High Intensity versus less intensive CRRT, outcome: 1.1 Mortality

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Analysis 1.1

Comparison 1 Intensive versus less intensive CRRT, Outcome 1 Mortality.

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Analysis 1.2

Comparison 1 Intensive versus less intensive CRRT, Outcome 2 Mortality in prespecified groups.

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Analysis 1.3

Comparison 1 Intensive versus less intensive CRRT, Outcome 3 Recovery of kidney function.

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Analysis 1.4

Comparison 1 Intensive versus less intensive CRRT, Outcome 4 Kidney function recovery in prespecified subgroup.

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Analysis 1.5

Comparison 1 Intensive versus less intensive CRRT, Outcome 5 Length of stay.

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Analysis 1.6

Comparison 1 Intensive versus less intensive CRRT, Outcome 6 Metabolic control.

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Analysis 1.7

Comparison 1 Intensive versus less intensive CRRT, Outcome 7 Adverse events.

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Summary of findings for the main comparison. Intensive versus less intensive continuous renal replacement therapy (CRRT) for acute kidney injury (AKI)

Intensive versus less intensive CRRT for AKI
Patient or population: patients with AKI Settings: ICU Intervention: Intensive versus less intensive CRRT
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Less intensive CRRT	Intensive CRRT
Mortality at day 30 Follow‐up: 30 days	Study population		RR 0.88 (0.81 to 1.1)	2402 (5)	⊕⊕⊝⊝ low^1,2
	430 per 1000	420 per 1000 (412 to 523)
	Moderate

Mortality after 30 days post‐randomisation Follow‐up: 60 days	Study population		RR 0.92 (0.80 to 1.06)	2759 (5)	⊕⊕⊝⊝ low^1,2
	514 per 1000	483 per 1000 (416 to 565)
	Moderate
	593 per 1000	557 per 1000 (480 to 652)
Patients free of RRT after discontinuing CRRT Follow‐up: 30 days	Study population		RR 1.12 (0.91 to 1.37)	2402 (5)	⊕⊕⊝⊝ low^1,2
	483 per 1000	541 per 1000 (439 to 661)
	Moderate
	390 per 1000	437 per 1000 (355 to 534)
Patients free of RRT after discontinuing CRRT Follow‐up: 90 days	Study population		RR 0.98 (0.94 to 1.01)	988 (3)	⊕⊕⊕⊝ moderate³
	923 per 1000	904 per 1000 (867 to 932)
	Moderate
	800 per 1000	784 per 1000 (752 to 808)
Adverse events: hypophosphataemia	Study population		RR 1.21 (1.11 to 1.31)	1441 (1)	⊕⊕⊕⊕ high
	540 per 1000	654 per 1000 (600 to 708)
	Moderate
	540 per 1000	653 per 1000 (599 to 707)
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval/s; RR: Risk ratio; RRT: renal replacement therapy
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ inconsistency: due to substantial heterogeneity (I² values ranged from 73% to 78%) ² imprecision: due to wide CI which crossed the threshold for clinically meaningful effects ³ Indirectness: critically ill patients with AKI in CRRT have high short‐term mortality risk; mortality is a competing end point for kidney recovery at day 90

Summary of findings for the main comparison. Intensive versus less intensive continuous renal replacement therapy (CRRT) for acute kidney injury (AKI)

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Summary of findings 2. Intensive versus less intensive continuous renal replacement therapy (CRRT) for acute kidney injury (AKI): subgroups

Intensive versus less intensive CRRT for AKI: subgroups
Patient or population: patients with AKI who need CRRT Settings: ICU Intervention: Intensive CRRT Comparison: Less intensive CRRT
Outcomes	*Illustrative comparative risks (95% CI)**		Relative effect (95% CI)	No. of participants (studies)	Quality of the evidence (GRADE)	Comments
	Assumed risk	Corresponding risk
	Standard dose	High dose
Mortality: patients with sepsis Follow‐up: mean 28 days	Study population		RR 0.94 (0.69 to 1.27)	966 (5)	⊕⊕⊝⊝ low^1,2
	524 per 1000	492 per 1000 (361 to 665)
	Moderate
	618 per 1000	581 per 1000 (426 to 785)
Mortality: patients without sepsis Follow‐up: mean 28 days	Study population		RR 0.89 (0.69 to 1.15)	1216 (4)	⊕⊕⊝⊝ low^1,2
	465 per 1000	414 per 1000 (321 to 535)
	Moderate
	564 per 1000	502 per 1000 (389 to 649)
Mortality: patients with AKI related to cardiac or general surgery Follow‐up: mean 21 days	Study population		RR 0.73 (0.61 to 0.88)	531 (2)	⊕⊕⊕⊕ high
	505 per 1000	368 per 1000 (308 to 444)
	Moderate
	459 per 1000	335 per 1000 (280 to 404)
Mortality: patients with AKI not related to surgery Follow‐up: mean 30 days	Study population		RR 0.94 (0.73 to 1.20)	1871 (3)	⊕⊕⊝⊝ low^1,2
	414 per 1000	389 per 1000 (302 to 497)
	Moderate
	550 per 1000	517 per 1000 (402 to 660)
The basis for the assumed risk* (e.g. the median control group risk across studies) is provided in footnotes. The corresponding risk (and its 95% confidence interval) is based on the assumed risk in the comparison group and the relative effect of the intervention (and its 95% CI). CI: Confidence interval/s; RR: Risk ratio
GRADE Working Group grades of evidence High quality: Further research is very unlikely to change our confidence in the estimate of effect. Moderate quality: Further research is likely to have an important impact on our confidence in the estimate of effect and may change the estimate. Low quality: Further research is very likely to have an important impact on our confidence in the estimate of effect and is likely to change the estimate. Very low quality: We are very uncertain about the estimate.
¹ inconsistency: due to substantial heterogeneity (I² values ranged from 73% to 78%) ² imprecision: due to wide CI which crossed the threshold for clinically meaningful effects

Summary of findings 2. Intensive versus less intensive continuous renal replacement therapy (CRRT) for acute kidney injury (AKI): subgroups

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Comparison 1. Intensive versus less intensive CRRT

Outcome or subgroup title	No. of studies	No. of participants	Statistical method	Effect size
1 Mortality Show forest plot	6		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

1.1 Mortality at day 30	5	2402	Risk Ratio (M‐H, Random, 95% CI)	0.88 [0.71, 1.08]
1.2 Mortality after 30 days post‐randomisation	5	2759	Risk Ratio (M‐H, Random, 95% CI)	0.92 [0.80, 1.06]
2 Mortality in prespecified groups Show forest plot	5		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

2.1 Patients with sepsis	5	966	Risk Ratio (M‐H, Random, 95% CI)	0.94 [0.69, 1.27]
2.2 Patients without sepsis	4	1216	Risk Ratio (M‐H, Random, 95% CI)	0.89 [0.69, 1.15]
2.3 Patients with SOFA cardiovascular score < 3	1	404	Risk Ratio (M‐H, Random, 95% CI)	0.91 [0.71, 1.18]
2.4 Patients with SOFA cardiovascular ≥ 3	1	1056	Risk Ratio (M‐H, Random, 95% CI)	1.04 [0.92, 1.18]
2.5 Patients with AKI related to surgical causes	2	531	Risk Ratio (M‐H, Random, 95% CI)	0.73 [0.61, 0.88]
2.6 Patients with AKI unrelated to surgical causes	3	1871	Risk Ratio (M‐H, Random, 95% CI)	0.94 [0.73, 1.20]
3 Recovery of kidney function Show forest plot	5		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

3.1 Free of RRT after discontinuing CRRT	5	2402	Risk Ratio (M‐H, Random, 95% CI)	1.12 [0.91, 1.37]
3.2 Free of RRT after discontinuing CRRT at day 30	5	1416	Risk Ratio (M‐H, Random, 95% CI)	1.03 [0.96, 1.11]
3.3 Free of RRT after discontinuing CRRT at day 90	3	988	Risk Ratio (M‐H, Random, 95% CI)	0.98 [0.94, 1.01]
4 Kidney function recovery in prespecified subgroup Show forest plot	5		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

4.1 Patients with AKI related to surgical causes	2	531	Risk Ratio (M‐H, Random, 95% CI)	1.27 [1.05, 1.53]
4.2 Patients with AKI related to non‐surgical causes	3	1870	Risk Ratio (M‐H, Random, 95% CI)	1.12 [0.73, 1.71]
5 Length of stay Show forest plot	2		Mean Difference (IV, Random, 95% CI)	Subtotals only

5.1 Days in hospital	2	1665	Mean Difference (IV, Random, 95% CI)	‐0.23 [‐3.35, 2.89]
5.2 Days in ICU	2	1665	Mean Difference (IV, Random, 95% CI)	‐0.58 [‐3.73, 2.56]
6 Metabolic control Show forest plot	1		Risk Ratio (M‐H, Random, 95% CI)	Totals not selected

6.1 Normalised metabolic acidosis	1		Risk Ratio (M‐H, Random, 95% CI)	0.0 [0.0, 0.0]
7 Adverse events Show forest plot	3		Risk Ratio (M‐H, Random, 95% CI)	Subtotals only

7.1 Patients experiencing adverse events	3	1753	Risk Ratio (M‐H, Random, 95% CI)	1.08 [0.73, 1.61]
7.2 Hypophosphataemia	1	1441	Risk Ratio (M‐H, Random, 95% CI)	1.21 [1.11, 1.31]
7.3 Hypokalaemia	1	1455	Risk Ratio (M‐H, Random, 95% CI)	0.96 [0.80, 1.15]
7.4 Arrhythmia	1	1463	Risk Ratio (M‐H, Random, 95% CI)	0.92 [0.80, 1.06]
7.5 Bleeding	3	1775	Risk Ratio (M‐H, Random, 95% CI)	0.78 [0.27, 2.24]

Comparison 1. Intensive versus less intensive CRRT

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Intensidad de la terapia de reemplazo renal continua para la insuficiencia renal aguda

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