BACKGROUND The optimal timing of renal replacement therapy (RRT) initiation is debatable. Many articles in this field enrolled trials not based on acute kidney injury. The safety of the watchful waiting strategy has not been fully discussed, and late RRT initiation criteria vary across studies. The effect of early RRT initiation in the AKI population with high plasma neutrophil gelatinase-associated lipocalin (NGAL) has not been examined yet. METHODS In accordance with PRISMA guidelines, the PubMed, Embase, and Cochrane databases were systemically searched for randomized controlled trials (RCTs). Trials not conducted in the AKI population were excluded. Data of study characteristics, primary outcome (all-cause mortality), and related secondary outcomes [mechanical ventilation (MV) days, length of hospital stay, RRT days, and length of ICU stay] were extracted. The outcomes were compared between early and late RRT groups by estimating the pooled odds ratio (OR) for binary outcomes and the weighted mean difference for continuous outcomes. Prospective trials were also examined and analyzed using the same method. RESULTS Nine RCTs with 1938 patients were included. Early RRT did not provide a survival benefit (pooled OR, 0.88; 95% confidence interval [CI] 0.62-1.27). However, the early RRT group had significantly fewer MV days (pooled mean difference, - 3.98 days; 95% CI - 7.81 to - 0.15 days). Subgroup analysis showed that RCTs enrolling the surgical population (P = .001) and the AKI population with high plasma NGAL (P = .031) had favorable outcomes regarding RRT days in the early initiation group. Moreover, 6 of 9 RCTs were selected for examining the safety of the watchful waiting strategy, and no significant differences were found in primary and secondary outcomes between the early and late RRT groups. CONCLUSIONS Overall, early RRT initiation did not provide a survival benefit, but a possible benefit of fewer MV days was detected. Early RRT might also provide the benefit of shorter MV or RRT support in the surgical population and in AKI patients with high plasma NGAL. Depending on the conventional indication for RRT initiation, the watchful waiting strategy is safe on the basis of all primary and secondary outcomes.

中文翻译：

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在重症急性肾损伤人群中观察等待策略与早期开始肾脏替代治疗之间的比较：更新的系统评价和荟萃分析。

背景技术肾脏替代治疗（RRT）启动的最佳时机尚待商.。该领域的许多文章都纳入了并非基于急性肾损伤的试验。警惕等待策略的安全性尚未得到充分讨论，RRT的晚期启动标准因研究而异。尚未研究早期血浆高嗜中性白细胞明胶酶相关脂钙蛋白（NGAL）对AKI人群RRT早期启动的影响。方法按照PRISMA指南，对PubMed，Embase和Cochrane数据库进行系统搜索，以寻找随机对照试验（RCT）。未在AKI人群中进行的试验被排除在外。研究特征，主要结局（全因死亡率）和相关的次要结局数据[机械通气（MV）天，住院时间，RRT天，和ICU住院时间]。通过估计二元结局的合并比值比（OR）和连续结局的加权平均差，比较早期和晚期RRT组之间的结局。还使用相同的方法检查和分析了前瞻性试验。结果包括9项RCT和1938例患者。早期RRT不能提供生存益处（合并OR为0.88； 95％置信区间[CI] 0.62-1.27）。但是，早期RRT组的MV天明显减少（合并平均差-3.98天； 95％CI-7.81至-0.15天）。亚组分析显示，在早期开始组中，接受手术的人群（P = .001）和血浆NGAL高的AKI人群（P = .031）的RCT在RRT天数方面有良好的预后。此外，在9个RCT中选择了6个以检查观察等待策略的安全性，在早期和晚期RRT组之间的主要和次要结局方面均未发现显着差异。结论总体而言，早期RRT不能提供生存获益，但可以检测到更少的MV天数。早期RRT还可为手术人群和血浆NGAL高的AKI患者提供较短的MV或RRT支持。根据常规的RRT启动指示，基于所有主要和次要结果，警惕的等待策略是安全的。但检测到减少MV天的可能好处。早期RRT还可为手术人群和血浆NGAL高的AKI患者提供较短的MV或RRT支持。根据常规的RRT启动指示，基于所有主要和次要结果，警惕的等待策略是安全的。但检测到减少MV天的可能好处。早期RRT还可为手术人群和血浆NGAL高的AKI患者提供较短的MV或RRT支持。根据常规的RRT启动指示，基于所有主要和次要结果，警惕的等待策略是安全的。