Peritoneal dialysis for acute kidney injury

What is the issue?

Acute kidney injury (AKI) is an abrupt and usually reversible decline in the glomerular filtration rate. No particular form of renal replacement therapy (treatment that replaces the normal blood-filtering function of the kidneys) for patients with AKI has been clearly shown to have a benefit. The choice of renal replacement therapy is dependent upon a variety of factors including availability, the expertise of the clinician, haemodynamic stability and so on.

What did we do?

This review aimed to evaluate the benefits and harms of peritoneal dialysis (PD) for patients with AKI compared with extracorporeal therapy (e.g. haemodialysis) or other types of PD. We searched the Cochrane Kidney and Transplant Register of Studies.

What did we find?

Six randomised controlled trials (484 patients) met our inclusion criteria. Five studies compared high volume PD with daily haemodialysis, extended daily haemodialysis, or continuous renal replacement therapy, and one study compared different intensities of PD on AKI patients. Compared to extracorporeal therapy, PD probably made little or no difference to death due to any cause or recovery of kidney function. PD probably slightly reduces the amount of fluid removal compared to extracorporeal therapy, and probably made little or no difference to infectious complications. It is uncertain whether PD compared to extracorporeal therapy has any effects on weekly delivered Kt/V, correction of acidosis, or duration of dialysis.

One study (61 participants) reported little or no difference to death due to any cause, kidney function recovery, or infection between low and high and intensity PD. Weekly delivered Kt/V and fluid removal was lower with low compared to high intensity PD.

Conclusions

There is currently not enough evidence to determine whether there are significant differences in death due to any cause or recovery of kidney function between patients treated with PD, extracorporeal therapies, or intensity of PD.

Authors' conclusions: 

Based on moderate (mortality, recovery of kidney function), low (infectious complications), or very low certainty evidence (correction of acidosis) there is probably little or no difference between PD and extracorporeal therapy for treating AKI. Fluid removal (low certainty) and weekly delivered Kt/V (very low certainty) may be higher with extracorporeal therapy.

Read the full abstract...
Background: 

Peritoneal dialysis (PD) has been suggested as an effective and safe dialysis modality in patients with acute kidney injury (AKI). However, whether PD is superior to extracorporeal therapy (e.g. haemodialysis) in terms of improving survival, recovery of kidney function, metabolic and clinical outcomes is still inconclusive.

Objectives: 

The aim of this review was to evaluate the benefits and harms of PD for patients with AKI compared with extracorporeal therapy or different PD modalities.

Search strategy: 

We searched the Cochrane Kidney and Transplant Register of Studies to 29 May 2017 through contact with the Information Specialist using search terms relevant to this review. Studies in the Register are identified through searches of CENTRAL, MEDLINE, and EMBASE, conference proceedings, the International Clinical Trials Register (ICTRP) Search Portal, and ClinicalTrials.gov. We also searched the China Biological Medicine Database.

Selection criteria: 

We included patients with AKI who were randomised to receive PD, extracorporeal therapy, or different PD modalities regardless of their age, sex, primary disease and clinical course.

Data collection and analysis: 

Screening, selection, data extraction and quality assessments for each retrieved article were carried out by two authors using standardised forms. Authors contacted when published data were incomplete. Statistical analyses were performed using the random effects model and results expressed as risk ratio (RR) with 95% confidence intervals (CI). Heterogeneity among studies was explored using the Cochran Q statistic and the I2 test. Outcomes of interest included all-cause mortality, recovery of kidney function, weekly delivered Kt/V, correction of acidosis, fluid removal, duration of dialysis, and infectious complications. Confidence in the evidence was assessing using GRADE.

Main results: 

Six studies (484 participants) met our inclusion criteria. Five studies compared high volume PD with daily haemodialysis, extended daily haemodialysis, or continuous renal replacement therapy. One study focused on the intensity of PD. The overall risk of bias was low to unclear. Compared to extracorporeal therapy, PD probably made little or no difference to all-cause mortality (4 studies, 383 participants: RR 1.12, 95% CI 0.81 to 1.55; I2 = 69%; moderate certainty evidence), or kidney function recovery (3 studies, 333 participants: RR 0.95, 95% CI 0.68 to 1.35; I2 = 0%; moderate certainty evidence). PD probably slightly reduces the amount of fluid removal compared to extracorporeal therapy (3 studies, 313 participants: MD -0.59 L/d, 95% CI -1.19 to 0.01; I2 = 89%; low certainty evidence), and probably made little or no difference to infectious complications (2 studies, 263 participants: RR 1.03, 95% CI 0.60 to 1.78; I2 = 0%; low certainty evidence). It is uncertain whether PD compared to extracorporeal therapy has any effects on weekly delivered Kt/V (2 studies, 263 participants: MD -2.47, 95% CI -5.17 to 0.22; I2 = 99%; very low certainty evidence), correction of acidosis (2 studies, 89 participants: RR 1.32, 95% CI 0.13 to 13.60; I2 = 96%; very low certainty evidence), or duration of dialysis (2 studies, 170 participants: MD -1.01 hours, 95% CI -91.49 to 89.47; I2 = 98%; very low certainty evidence). Heterogeneity was high and this may be due to the different extracorporeal therapies used.

One study (61 participants) reported little or no difference to all-cause mortality, kidney function recovery, or infection between low and high and intensity PD. Weekly delivered Kt/V and fluid removal was lower with low compared to high intensity PD.

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