Bhatt GC, Das RR, Satapathy A: Early versus Late Initiation of Renal Replacement Therapy: Have We Reached the Consensus? An Updated Meta-Analysis. Nephron DOI 10.1159/000515129
The added patient-centered benefit of early versus late initiation of hemodialysis (HD) therapy for patients with severe AKI has been widely debated for many years without a clear resolution, largely due to the extreme heterogeneity of the etiology of AKI and difficulties in predicting its natural history at the time of diagnosis using conventional KDIGO-based criteria. However, recent trials have strongly suggested that early (pre-symptomatic) initiation of HD has no measurable benefit, results in unnecessary use of HD, and might, in fact, lead to harm due to unavoidable effects of HD.
Bhatt and coworkers have evaluated the current state-of-the-art concerning the timing of HD initiation in AKI in a systematic review and meta-analysis of 14 published randomized controlled trials involving 5,234 patients with AKI between 1997 and 2020.
The pooled estimates of differences between early and late initiation of HD for AKI showed no difference in multiple analyses, including 30- and 90-day mortality and length of hospital or ICU stay. Dialysis dependence at 90 days was increased in those with early HD initiation. Hypotension and hypophosphatemia were increased in the early HD cohorts, as were healthcare resource utilizations.
Delaying HD initiation in patients meeting the definition of AKI accompanied by close monitoring and use of clinical and laboratory indications (e.g., volume overload, acidosis, hyperkalemia) for the timing of dialysis initiation should be the default position.