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Cochrane Database of Systematic Reviews

Intensity of continuous renal replacement therapy for acute kidney injury

Information

DOI:
https://doi.org/10.1002/14651858.CD010613.pub2Copy DOI
Database:
  1. Cochrane Database of Systematic Reviews
Version published:
  1. 04 October 2016see what's new
Type:
  1. Intervention
Stage:
  1. Review
Cochrane Editorial Group:
  1. Cochrane Kidney and Transplant Group

Copyright:
  1. 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

  1. Draft the protocol: AF, DB, AC

  2. Study selection: AF, DB

  3. Extract data from studies: AF, DB

  4. Enter data into RevMan: AF

  5. Carry out the analysis: AF, AC

  6. Interpret the analysis: AF, DB, AC

  7. Draft the final review: AF, DB, AC

  8. Disagreement resolution: AC

  9. 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

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.

Study flow diagram
Figures and Tables -
Figure 1

Study flow diagram

Risk of bias graph: review authors' judgements about each risk of bias item presented as percentages across all included studies
Figures and Tables -
Figure 2

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

Risk of bias summary: review authors' judgements about each risk of bias item for each included study
Figures and Tables -
Figure 3

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

Funnel plot of comparison: 1 High Intensity versus less intensive CRRT, outcome: 1.1 Mortality
Figures and Tables -
Figure 4

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

Comparison 1 Intensive versus less intensive CRRT, Outcome 1 Mortality.
Figures and Tables -
Analysis 1.1

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

Comparison 1 Intensive versus less intensive CRRT, Outcome 2 Mortality in prespecified groups.
Figures and Tables -
Analysis 1.2

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

Comparison 1 Intensive versus less intensive CRRT, Outcome 3 Recovery of kidney function.
Figures and Tables -
Analysis 1.3

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

Comparison 1 Intensive versus less intensive CRRT, Outcome 4 Kidney function recovery in prespecified subgroup.
Figures and Tables -
Analysis 1.4

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

Comparison 1 Intensive versus less intensive CRRT, Outcome 5 Length of stay.
Figures and Tables -
Analysis 1.5

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

Comparison 1 Intensive versus less intensive CRRT, Outcome 6 Metabolic control.
Figures and Tables -
Analysis 1.6

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

Comparison 1 Intensive versus less intensive CRRT, Outcome 7 Adverse events.
Figures and Tables -
Analysis 1.7

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

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)

⊕⊕⊝⊝
low1,2

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)

⊕⊕⊝⊝
low1,2

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)

⊕⊕⊝⊝
low1,2

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

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

⊕⊕⊝⊝
low1,2

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)

⊕⊕⊝⊝
low1,2

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)

⊕⊕⊝⊝
low1,2

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

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

Figures and Tables -
Comparison 1. Intensive versus less intensive CRRT