Early Renal Replacement Therapy Versus Standard Care in the ICU: A Systematic Review, Meta-Analysis, and Cost Analysis

Neutrophil gelatinase-associated lipocalin as predictor of acute kidney injury requiring renal replacement therapy: A systematic review and meta-analysis

Background

Patients with severe acute kidney injury (AKI) may require renal replacement therapy (RRT), such as hemodialysis and peritoneal dialysis. Neutrophil gelatinase-associated lipocalin (NGAL) is a sensitive indicator for early diagnosis and recognition of AKI; however, its predictive value of AKI-associated need for RRT needs further evaluation.

Methods

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines, relevant articles were systematically searched and selected from seven databases. The random effects model was applied to evaluate the predictive performance of NGAL for AKI requiring RRT. The Newcastle–Ottawa Scale (NOS) was used to assess the quality of each included study.

Results

A total of 18 studies including 1,787 patients with AKI and having an average NOS score of 7.67 were included in the meta-analysis. For plasma/serum NGAL, the pooled sensitivity and specificity with corresponding 95% confidence interval (CI) were 0.75 (95% CI: 0.68–0.81) and 0.76 (95% CI: 0.70–0.81), respectively. The pooled positive likelihood ratio (PLR) was 2.9 (95% CI: 2.1–4.1), and the pooled negative likelihood ratio (NLR) was 0.34 (95% CI: 0.25–0.46). Subsequently, the pooled diagnostic odds ratio (DOR) was 9 (95% CI: 5–16) using a random effects model, and the area under the curve (AUC) of summary receiver operating characteristic to summarize predictive accuracy was 0.82 (95% CI: 0.79–0.85). For urine NGAL, the pooled sensitivity, specificity, PLR, NLR, DOR, and AUC values were 0.78 (95% CI: 0.61–0.90), 0.77 (95% CI: 0.65–0.85), 3.4 (95% CI: 2.4–4.8), 0.28 (95% CI: 0.15–0.52), 12 (95% CI: 6–24), and 0.84 (95% CI: 0.80–0.87), respectively.

Conclusion

Plasma/serum and urine NGAL levels performed comparably well in predicting AKI requiring RRT. Our findings suggested that NGAL is an effective predictive biomarker for the AKI-associated need for RRT. Nevertheless, more pieces of high-quality evidence and future trials with larger sample sizes are needed for further improvement of patient outcomes.

Systematic review registration

[https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022346595], identifier [CRD42022346595].

Organizational and financial aspects of a continuous renal replacement therapy program

Critically ill patients who develop severe acute kidney injury in the intensive care unit often require treatment with renal replacement therapies (RRTs). This complication is associated with severe morbidity and mortality and high costs, both during hospitalization and postdischarge. This article discusses the operational requirements to develop and conduct a RRT program, as well as the financial implications of this complex form of patient care. The management of these programs must occur in a context where a clear organizational and educational framework and a multidisciplinary team ensures safety, effectiveness, cost-control, and a clear quality control framework.

Search is a verb: systematic review searching as invisible labor

Invisible labor is a term used by labor economists to describe work that contributes, and is often even necessary, to the economy but largely goes unrecognized and unpaid. Despite the fact that systematic review searching is a significant task for many librarians and knowledge professionals, the search process can be considered a form of invisible labor because it often goes without recognition. This occurs sometimes through not granting authorship to the librarian who performed the intellectual contribution of search development and sometimes through a devaluing of the search process by the choice of language used to describe the search. By using the term search as a passive verb or noun, authors devalue the real intellectual labor involved in searching, which includes decisions related to search terms and combinations, database selection, and other search parameters. This commentary explores the context of how searching is described through the concept of invisible labor.

Delirium and Associated Length of Stay and Costs in Critically Ill Patients

Purpose

Delirium frequently affects critically ill patients in the intensive care unit (ICU). The purpose of this study is to evaluate the impact of delirium on ICU and hospital length of stay (LOS) and perform a cost analysis.

Materials and Methods

Prospective studies and randomized controlled trials of patients in the ICU with delirium published between January 1, 2015, and December 31, 2020, were evaluated. Outcome variables including ICU and hospital LOS were obtained, and ICU and hospital costs were derived from the respective LOS.

Results

Forty-one studies met inclusion criteria. The mean difference of ICU LOS between patients with and without delirium was significant at 4.77 days (p < 0.001); for hospital LOS, this was significant at 6.67 days (p < 0.001). Cost data were extractable for 27 studies in which both ICU and hospital LOS were available. The mean difference of ICU costs between patients with and without delirium was significant at $3,921 (p < 0.001); for hospital costs, the mean difference was $5,936 (p < 0.001).

Conclusion

ICU and hospital LOS and associated costs were significantly higher for patients with delirium, compared to those without delirium. Further research is necessary to elucidate other determinants of increased costs and cost-reducing strategies for critically ill patients with delirium. This can provide insight into the required resources for the prevention of delirium, which may contribute to decreasing healthcare expenditure while optimizing the quality of care.

Time to Initiation of Renal Replacement Therapy Among Critically Ill Patients With Acute Kidney Injury: A Current Systematic Review and Meta-Analysis

OBJECTIVES

The optimal time to initiate renal replacement therapy in critically ill patients with acute kidney injury is controversial. We investigated the effect of such earlier versus later initiation of renal replacement therapy on the primary outcome of 28-day mortality and other patient-centered secondary outcomes.

DESIGN

We searched MEDLINE (via PubMed), EMBASE, and Cochrane databases to July 17, 2020, and included randomized controlled trials comparing earlier versus later renal replacement therapy.

SETTING

Multiple centers involved in eight trials.

PATIENTS

Total of 4,588 trial participants.

INTERVENTION

Two independents investigators screened and extracted data using a predefined form. We selected randomized controlled trials in critically ill adult patients with acute kidney injury and compared of earlier versus later initiation of renal replacement therapy regardless of modality.

MEASUREMENTS AND MAIN RESULTS

Overall, 28-day mortality was similar between earlier and later renal replacement therapy initiation (38.43% vs 38.06%, respectively; risk ratio, 1.01; [95% CI, 0.94-1.09]; I2 = 0%). Earlier renal replacement therapy, however, shortened hospital length of stay (mean difference, -2.14 d; [95% CI, -4.13 to -0.14]) and ICU length of stay (mean difference, -1.18 d; [95% CI, -1.95 to -0.42]). In contrast, later renal replacement therapy decreased the use of renal replacement therapy (relative risk, 0.69; [95% CI, 0.58-0.82]) and lowered the risk of catheter-related blood stream infection (risk ratio, 0.50, [95% CI, 0.29-0.86). Among survivors, renal replacement therapy dependence at day 28 was similar between earlier and later renal replacement therapy initiation (risk ratio, 0.98; [95% CI, 0.66-1.40]).

CONCLUSIONS

Earlier or later initiation of renal replacement therapy did not affect mortality. However, earlier renal replacement therapy was associated with significantly shorter ICU and hospital length of stay, whereas later renal replacement therapy was associated with decreased use of renal replacement therapy and decreased risk of catheter-related blood stream infection. These findings can be used to guide the management of critically ill patients with acute kidney injury.

Dynamic Assessment of Fluid Responsiveness in Surgical ICU Patients Through Stroke Volume Variation is Associated With Decreased Length of Stay and Costs: A Systematic Review and Meta-Analysis

Static indices, such as the central venous pressure, have proven to be inaccurate predictors of fluid responsiveness. An emerging approach uses dynamic assessment of fluid responsiveness (FT-DYN), such as stroke volume variation (SVV) or surrogate dynamic variables, as more accurate measures of volume status. Recent work has demonstrated that goal-directed therapy guided by FT-DYN was associated with reduced intensive care unit (ICU) mortality; however, no study has specifically assessed this in surgical ICU patients. This study aimed to conduct a systematic review and meta-analysis on the impact of employing FT-DYN in the perioperative care of surgical ICU patients on length of stay in the ICU. As secondary objectives, we performed a cost analysis of FT-DYN and assessed the impact of FT-DYN versus standard care on hospital length of stay and mortality. We identified all randomized controlled trials (RCTs) through MEDLINE, EMBASE, and CENTRAL that examined adult patients in the ICU who were randomized to standard care or to FT-DYN from inception to September 2017. Two investigators independently reviewed search results, identified appropriate studies, and extracted data using standardized spreadsheets. A random effect meta-analysis was carried out. Eleven RCTs were included with a total of 1015 patients. The incorporation of FT-DYN through SVV in surgical patients led to shorter ICU length of stay (weighted mean difference [WMD], -1.43d; 95% confidence interval [CI], -2.09 to -0.78), shorter hospital length of stay (WMD, -1.96d; 95% CI, -2.34 to -1.59), and trended toward improved mortality (odds ratio, 0.55; 95% CI, 0.30-1.03). There was a decrease in daily ICU-related costs per patient for those who received FT-DYN in the perioperative period (WMD, US$ -1619; 95% CI, -2173.68 to -1063.26). Incorporation of FT-DYN through SVV in the perioperative care of surgical ICU patients is associated with decreased ICU length of stay, hospital length of stay, and ICU costs.