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
Login now to access Regular content available to all registered users.

You may also access this content "anytime, anywhere" with the Free MULTILEARNING App for iOS and Android
Rate & Comment (0)

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
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




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. 


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.


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.


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.


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.


1.   Hoste EAJ, Bagshaw SM, Bellomo R, Cely CM, Colman R, Cruz DN, et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study. Intensive Care Med [Internet]. 2015 Aug [cited 2016 Jul 15];41(8):1411–23. Available from: http://www.ncbi.nlm.nih.gov/pubmed/26162677
2.   Siew ED, Davenport A. The growth of acute kidney injury: a rising tide or just closer attention to detail? Kidney Int. 2015;87(1):46–61. 
3.   Lameire NH, Bagga A, Cruz D, De Maeseneer J, Endre Z, Kellum JA, et al. Acute kidney injury: an increasing global concern. Lancet. 2013;382(9887):170–9. 
4.   Gaudry S, Hajage D, Schortgen F, Martin-Lefevre L, Pons B, Boulet E, et al. Initiation Strategies for Renal-Replacement Therapy in the Intensive Care Unit. N Engl J Med [Internet]. 2016 May 15 [cited 2016 Jul 13];NEJMoa1603017. Available from: http://www.nejm.org/doi/10.1056/NEJMoa1603017
5.   Mehta RL. Renal-Replacement Therapy in the Critically Ill — Does Timing Matter? N Engl J Med [Internet]. 2016 Jul 14 [cited 2016 Jul 15];375(2):175–6. Available from: http://www.nejm.org/doi/10.1056/NEJMe1606125
6.   Section 5: Dialysis Interventions for Treatment of AKI. Kidney Int Suppl. 2012;2(1):89–115. 
7.   Zarbock A, Kellum JA, Schmidt C, Van Aken H, Wempe C, Pavenstädt H, et al. Effect of Early vs Delayed Initiation of Renal Replacement Therapy on Mortality in Critically Ill Patients With Acute Kidney Injury. Jama [Internet]. 2016; Available from: http://jama.jamanetwork.com/article.aspx?doi=10.1001/jama.2016.5828
8.   Wierstra BT, Kadri S, Alomar S, Burbano X, Barrisford GW, Kao RLC. The impact of 'early' versus 'late' initiation of renal replacement therapy in critical care patients with acute kidney injury: a systematic review and evidence synthesis. Crit Care [Internet]. 2016;20(1):122. Available from: http://ccforum.biomedcentral.com/articles/10.1186/s13054-016-1291-8
9.   Seabra VF, Balk EM, Liangos O, Sosa MA, Cendoroglo M, Jaber BL. Timing of Renal Replacement Therapy Initiation in Acute Renal Failure: A Meta-analysis. Am J Kidney Dis. 2008;52(2):272–84.
10.   Karvellas CJ, Farhat MR, Sajjad I, Mogensen SS, Leung A a, Wald R, et al. A comparison of early versus late initiation of renal replacement therapy in critically ill patients with acute kidney injury: a systematic review and meta-analysis. Crit care [Internet]. 2011;15(1):R72. Available from: http://ccforum.com/content/15/1/R72
11.   Bouman CS, Oudemans-Van Straaten HM, Tijssen JG, Zandstra DF, Kesecioglu J. Effects of early high-volume continuous venovenous hemofiltration on survival and recovery of renal function in intensive care patients with acute renal failure: a prospective, randomized trial. Crit Care Med [Internet]. 2002;30(10):2205–11. Available from: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=PubMed&dopt=Citation&list_uids=12394945
12.   Sugahara S. Early start on continuous hemodialysis therapy improves survival rate in patients with acute renal failure following coronary bypass surgery. Hemodial Int [Internet]. 2004 [cited 2016 Jul 12];8(4). Available from: http://resolver.scholarsportal.info/resolve/14927535/v08i0004/320_esochtrffcbs.xml
13.   Combes A, Bréchot N, Amour J, Cozic N, Lebreton G, Guidon C, et al. Early high-volume hemofiltration versus standard care for post-cardiac surgery shock the HEROICS study. Am J Respir Crit Care Med. 2015;192(10):1179–90.
14.   Durmaz I, Yagdi T, Calkavur T, Mahmudov R, Apaydin AZ, Posacioglu H, et al. Prophylactic Dialysis in Patients With Renal Dysfunction Undergoing On-Pump Coronary Artery Bypass Surgery. Ann Thorac Surg. 2003;75:859–64.
15.   Wald R, Adhikari NKJ, Smith OM, Weir MA, Pope K, Cohen A, et al. Comparison of standard and accelerated initiation of renal replacement therapy in acute kidney injury. Kidney Int. 2015;88:897–904.
16. Payen D, Mateo J, Cavaillon JM, Fraisse F, Floriot C, Vicaut E. Impact of continuous venovenous hemofiltration on organ failure during the early phase of severe sepsis: A randomized controlled trial*. Crit Care Med [Internet]. 2009 Mar [cited 2016 Jul 12];37(3):803–10. Available from: http://content.wkhealth.com/linkback/openurl?sid=WKPTLP:landingpage&an=00003246-200903000-00001

Document: File 1 File 2 File 3
    This eLearning portal is powered by:
    This eLearning portal is powered by MULTIEPORTAL
Anonymous User Privacy Preferences

Strictly Necessary Cookies (Always Active)

MULTILEARNING platforms and tools hereinafter referred as “MLG SOFTWARE” are provided to you as pure educational platforms/services requiring cookies to operate. In the case of the MLG SOFTWARE, cookies are essential for the Platform to function properly for the provision of education. If these cookies are disabled, a large subset of the functionality provided by the Platform will either be unavailable or cease to work as expected. The MLG SOFTWARE do not capture non-essential activities such as menu items and listings you click on or pages viewed.

Performance Cookies

Performance cookies are used to analyse how visitors use a website in order to provide a better user experience.

Save Settings