BACKGROUND The timing of renal replacement therapy (RRT) for severe acute kidney injury is highly debated when no life-threatening complications are present. We assessed whether a strategy of delayed versus early RRT initiation affects 28-day survival in critically ill adults with severe acute kidney injury. METHODS In this systematic review and individual patient data meta-analysis, we searched MEDLINE (via PubMed), Embase, and the Cochrane Central Register of Controlled Trials for randomised trials published from April 1, 2008, to Dec 20, 2019, that compared delayed and early RRT initiation strategies in patients with severe acute kidney injury. Trials were eligible for inclusion if they included critically ill patients aged 18 years or older with acute kidney injury (defined as a Kidney Disease: Improving Global Outcomes [KDIGO] acute kidney injury stage 2 or 3, or, where KDIGO was unavailable, a renal Sequential Organ Failure Assessment score of 3 or higher). We contacted the principal investigator of each eligible trial to request individual patient data. From the included trials, any patients without acute kidney injury or who were not randomly allocated were not included in the individual patient data meta-analysis. The primary outcome was all-cause mortality at day 28 after randomisation. This study is registered with PROSPERO (CRD42019125025). FINDINGS Among the 1031 studies identified, one study that met the eligibility criteria was excluded because the recruitment period was not recent enough, and ten (including 2143 patients) were included in the analysis. Individual patient data were available for nine studies (2083 patients), from which 1879 patients had severe acute kidney injury and were randomly allocated: 946 (50%) to the delayed RRT group and 933 (50%) to the early RRT group. 390 (42%) of 929 patients allocated to the delayed RRT group and who had available data did not receive RRT. The proportion of patients who died by day 28 did not significantly differ between the delayed RRT group (366 [44%] of 837) and the early RRT group (355 [43%] of 827; risk ratio 1·01 [95% CI 0·91 to 1·13], p=0·80), corresponding to an overall risk difference of 0·01 (95% CI -0·04 to 0·06). There was no heterogeneity across studies (I2=0%; τ2=0), and most studies had a low risk of bias. INTERPRETATION The timing of RRT initiation does not affect survival in critically ill patients with severe acute kidney injury in the absence of urgent indications for RRT. Delaying RRT initiation, with close patient monitoring, might lead to a reduced use of RRT, thereby saving health resources. FUNDING None.

中文翻译：

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严重急性肾损伤的肾脏替代治疗的延迟开始与早期开始：系统评价和随机临床试验的个体患者数据荟萃分析。

背景技术当不存在危及生命的并发症时，针对严重急性肾损伤的肾脏替代疗法（RRT）的时机已受到广泛争议。我们评估了延迟和早期RRT启动策略是否对重症急性肾损伤重症成人的28天生存期有影响。方法在这项系统的回顾和个体患者数据的荟萃分析中，我们搜索了MEDLINE（通过PubMed），Embase和对照试验的Cochrane中央登记册，收集了从2008年4月1日至2019年12月20日进行的随机试验，比较了重度急性肾损伤患者的早期RRT启动策略。如果试验包括年龄在18岁以上且患有急性肾损伤（定义为肾脏疾病）的重症患者，则有资格纳入研究。改善总体结果[KDIGO] 2或3期急性肾损伤，或者在KDIGO不可用的情况下，其肾脏序贯器官衰竭评估得分为3或更高。我们联系了每个符合条件的试验的主要研究人员，以索取患者的个人数据。从纳入的试验中，任何没有急性肾损伤或未随机分配的患者均不包括在患者数据荟萃分析中。主要结果是随机分组后第28天的全因死亡率。该研究已在PROSPERO（CRD42019125025）中注册。结果在确定的1031项研究中，一项符合入选标准的研究被排除在外，因为招募期还不够近，分析中包括了10项（包括2143例患者）。有九项研究（2083例患者）的个人患者数据，其中1879例严重急性肾损伤患者被随机分配：延迟RRT组946例（50％），早期RRT组933例（50％）。929名分配到延迟RRT组且有可用数据的患者中，有390名（42％）没有接受RRT。延迟RRT组（837的366 [44％]）和早期RRT组（827的355 [43％]）在第28天死亡的患者比例没有显着差异；风险比1·01 [95％CI 0·91至1·13]，p = 0·80），对应于整体风险差异为0·01（95％CI -0·04至0·06）。研究之间没有异质性（I2 = 0％；τ2= 0），并且大多数研究偏倚风险低。解释在没有RRT紧急指征的情况下，RRT启动的时间不会影响重症急性肾损伤重症患者的生存。延迟RRT启动，密切监视患者，可能会减少RRT的使用，从而节省医疗资源。资金无。