Early Dialysis vs Standard Care in the ICU: A Systematic Review and Cost-Analysis
CCCF ePoster library. Herritt B. Oct 31, 2016; 150883; 5
Dr. Brent Herritt
Dr. Brent Herritt
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Topic: Systematic Review, Meta-analysis, or Meta-synthesis

Early Dialysis vs Standard Care in the ICU: A Systematic Review and Cost-Analysis


Herrit, Brent1; Chaudhuri, Dipayan1; Philippe-Gagnon, Louise2Thavorn, Kednapa3Kobewka, Daniel1Kyeremanteng, Kwadwo4

1. Department of Internal Medicine, University of Ottawa, Ottawa, ON, Canada
2. Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
3. 
Ottawa Hospital Research Institute, The Ottawa Hospital, Ottawa, ON, Canada
4. Division of Critical Care and Department of Internal Medicine, University of Ottawa, Ottawa, ON, Canada

 


Abstract:

Introduction

The incidence of acute kidney injury (AKI) in critical care settings has been reported to range between 30% - 60% (1,2). Multiple studies have shown that AKI severity in the intensive care unit (ICU) is associated with increased mortality and higher rates of chronic kidney disease (CKD) (1–3).  Renal replacement therapy (RRT) is the treatment of choice for severe AKI but there are no firm guidelines as to the time of initiation of renal replacement therapy in the critically ill (4,5,6). There have been several reviews conducted on this topic (8–10), which have yielded contradictory results. Until recently, most studies in this area have been observational studies with only a few, small RCTs (11-16).

Given the recent publication of two large RCTs (7,15) with conflicting results, we have re-examined the evidence to ascertain a difference between early dialysis vs standard care. Furthermore, to our knowledge no cost-analysis has been conducted to evaluate the impact of early vs late dialysis. 

Objectives

The primary endpoint of this study is to determine the effect of early vs. late dialysis initiation on 1 month mortality rates for patients admitted to the ICU. As secondary endpoints, we provide a cost analysis of early vs late RRT initiation. We also examine other secondary endpoints including ICU length of stay (LOS), hospital LOS, and number of patients on dialysis at day 60 post randomization.

Methods

We identified all randomized control trails that examined adult patients admitted to ICU who were randomized to either early RRT vs standard care. Eligbility criteria were: Randomized control trials after the year 2000, the population evaluated had to be adults over the age of 18 admitted to the ICU, the intervention being examined had to be early renal replacement versus standard care and outcomes had to measure patient mortality. We searched both MEDLINE and EMBASE for relevant studies on July 6, 2016. Risk of bias assessment was conducted using the Cochrane risk of bias tool for randomized studies.

Results

7 RCTs were included in the systematic review. The pooled 30 day mortality for the early RRT group was 36.5% (260/711) and 39.8% (274/689) for the standard treatment group.  Overall, early RRT showed no survival benefit when compared to standard treatment (odds ratio [OR], 0.90 [95% confidence interval [95% CI] 0.70 – 1.15], p > 0.05]. When a subgroup analysis was performed based on type of patient population and early RRT criteria, there was also no significant differences within subgroups.

There was a trend towards decreased length of hospital stay in patients with early RRT of -1.65 days (95% CI -5.54 to 2.24, p = 0.334). Considerable heterogeneity existed between studies (I2 = 57.8%). There was no significant difference in length of ICU stay (mean difference of 0.79 days [95% CI -2.09 to 0.52], p=0.238) or proportion of patients on dialysis at day 60 (OR 0.93 [95% CI 0.61 to 1.41], p=0.788). Per patient, the early RRT group cost $109 less in ICU resources and $716 dollars less in total cost. There was also a weighted average of 533.18 RRT days in the early arm per patient vs  478.06 RRT days in the standard care. With dialysis costing $1423 to $4046 per day, this indicates early RRT may be more costly.

Conclusion

Our study shows that across all measured domains there is no clear benefit to early RRT. Moreover, this intervention likely results in increased costs and exposes more patients to an invasive therapy with potential harm.


References:

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