Background Urinary liver-type fatty acid–binding protein (L-FABP) is a proximal tubular injury candidate biomarker for early detection of acute kidney injury (AKI), with variable performance ...characteristics depending on clinical settings. Study Design Meta-analysis of diagnostic test studies assessing the performance of urinary L-FABP in AKI. Setting & Population Literature search in MEDLINE, EMBASE, Scopus, Google Scholar, Cochrane Central Register of Controlled Trials, and ClinicalTrials.gov using search terms “liver-type fatty acid-binding protein” and “L-FABP.” Selection Criteria for Studies Studies of humans investigating the performance characteristics of urinary L-FABP for the early diagnosis of AKI and AKI-related outcomes, including dialysis requirement and mortality. Predictor Urinary L-FABP. Outcomes Diagnosis of AKI, dialysis requirement, and in-hospital death. Results 15 prospective cohort and 2 case-control studies were identified. Only 7 cohort studies could be meta-analyzed. The estimated sensitivity of urinary L-FABP level for the diagnosis of AKI was 74.5% (95% CI, 60.4%-84.8%), and specificity was 77.6% (95% CI, 61.5%-88.2%). The estimated sensitivity of urinary L-FABP level for predicting dialysis requirement was 69.1% (95% CI, 34.6%-90.5%), and specificity was 42.7% (95% CI, 3.1%-94.5%); for in-hospital mortality, sensitivity and specificity were 93.2% (95% CI, 66.2%-99.0%) and 78.8% (95% CI, 27.0%-97.4%), respectively. Limitations Paucity and low quality of studies, different clinical settings, and variable definitions of AKI. Conclusions Although urinary L-FABP may be a promising biomarker for early detection of AKI and prediction of dialysis requirement and in-hospital mortality, its potential value needs to be validated in large studies and across a broader spectrum of clinical settings.
Background The proportion of patients with advanced chronic kidney disease (CKD) initiating dialysis therapy at a higher glomerular filtration rate (GFR) has increased during the past decade. Recent ...data suggest that higher GFR may be associated with increased mortality. Study Design A meta-analysis of cohort studies and trials. Setting & Population Patients with advanced CKD. Selection Criteria for Studies We performed a systematic literature search in MEDLINE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov , American Society of Nephrology abstracts, and bibliographies of retrieved articles to identify studies reporting on GFR at dialysis therapy initiation and mortality. Predictor Estimated or calculated GFR at dialysis therapy initiation. Outcome Pooled adjusted hazard ratio (HR) of continuous GFR for all-cause mortality. Results 16 cohort studies and 1 randomized controlled trial were identified (n = 1,081,116). By meta-analysis restricted to 15 cohorts (n = 1,079,917), higher GFR at dialysis therapy initiation was associated with a higher pooled adjusted HR for all-cause mortality (1.04; 95% CI, 1.03-1.05; P < 0.001). However, there was significant heterogeneity ( I2 = 97%; P < 0.001). The association persisted among the 9 cohorts that adjusted analytically for nutritional covariates (HR, 1.03; 95% CI, 1.02-1.04; P < 0.001; residual I2 = 97%). The highest mortality risk was observed in hemodialysis cohorts (HR, 1.05; 95% CI, 1.02-1.08; P < 0.001), whereas there was no association between GFR and mortality in peritoneal dialysis cohorts (HR, 1.04; 95% CI, 0.99-1.08, P = 0.1; residual I2 = 98%). Finally, higher GFR was associated with a lower mortality risk in cohorts that calculated GFR (HR, 0.80; 95% CI, 0.71-0.91; P = 0.003), contrasting with a higher mortality risk in cohorts that estimated GFR (HR, 1.04; 95% CI, 1.03-1.05; P < 0.001; residual I2 = 97%). Limitations Paucity of randomized controlled trials, different methods for determining GFR, and substantial heterogeneity. Conclusions Higher estimated rather than calculated GFR at dialysis therapy initiation is associated with a higher mortality risk in patients with advanced CKD, independent of nutritional status. Although there was substantial heterogeneity of effect size estimates across studies, this observation requires further study.
Background Increased left ventricular (LV) mass is a risk factor for cardiovascular mortality in patients with chronic kidney failure. More frequent or extended hemodialysis (HD) has been ...hypothesized to have a beneficial effect on LV mass. Study Design Meta-analysis. Setting & Population MEDLINE literature search (inception to April 2011), Cochrane Central Register of Controlled Trials and ClinicalTrials.gov using the search terms “short daily HD,” “daily HD,” “quotidian HD,” “frequent HD,” “intensive HD,” “nocturnal HD,” and “home HD.” Selection Criteria for Studies Single-arm cohort studies (with pre- and post-study evaluations) and trials examining the effect of frequent or extended HD on cardiac morphology and function and blood pressure parameters. Studies of hemofiltration, hemodiafiltration, and peritoneal dialysis were excluded. Intervention Frequent (2-8 hours, >3 times weekly) or extended (>4 hours, 3 times weekly) HD compared with conventional (≤4 hours, 3 times weekly) HD. Outcomes Absolute changes in cardiac morphology and function, including LV mass index (LVMI; primary) and blood pressure parameters (secondary). Results We identified 38 single-arm studies, 5 crossover trials, and 3 randomized controlled trials. By meta-analysis of 23 study arms, frequent or extended HD significantly reduced LVMI from baseline (−31.2 g/m2 , 95% CI, −39.8 to −22.5; P < 0.001). The 3 randomized trials found a less pronounced net reduction in LVMI (−7.0 g/m2 ; 95% CI, −10.2 to −3.7; P < 0.001). LV ejection fraction improved by 6.7% (95% CI, 1.6% to 11.9%; P = 0.01). Other cardiac morphologic parameters showed similar improvements. There also were significant decreases in systolic, diastolic, and mean blood pressure and mean number of antihypertensive medications. Limitations Paucity of randomized controlled trials. Conclusions Conversion from conventional to frequent or extended HD is associated with improvements in cardiac morphology and function, including LVMI and LV ejection fraction, respectively, and several blood pressure parameters, which collectively might confer long-term cardiovascular benefit. Trials with long-term clinical outcomes are needed.
Abstract Background Several studies have examined the potential benefits of continuous vs intermittent (bolus) intravenous loop diuretic administration in hospitalized patients with conflicting ...results. We conducted a meta-analysis to compare the efficacy of these 2 strategies in hospitalized adults and children with extracellular fluid volume expansion. Methods We searched MEDLINE (through October 2012) and prior meta-analyses for randomized controlled trials comparing the efficacy of continuous vs intermittent infusion of loop diuretics. Random-effects model meta-analyses were performed to examine several outcomes, including net change in urine output and body weight. Results We identified 7 crossover and 11 parallel-arm randomized controlled trials (936 patients) of adults and children. In the 15 studies of adults, continuous loop diuretic infusion resulted in a nonsignificant net increase in daily urine output of 334 mL (95% confidence interval CI, − 74 to 742; P = .11) relative to the bolus infusion. In the 8 studies that used a loading dose, continuous loop diuretic infusion resulted in a significant net increase in daily urine output of 294 mL (95% CI, 31-557; P = .03) relative to the intermittent infusion. There was also a significant net decrease in body weight of 0.78 kg (95% CI, − 1.54 to − 0.03; P = .04) in the continuous relative to the intermittent loop diuretic infusion. In the 3 studies of children, there was no demonstrable effect on daily urine output or body weight. Conclusion Continuous infusion of loop diuretics preceded by a loading dose results in greater diuresis in hospitalized adults with extracellular fluid volume expansion compared with intermittent dosing regimens. Further studies are required to examine whether these benefits translate into improved clinical outcomes.
Recognition is increasing for the effect of AKI on patients, and the resulting societal burden from its long-term effects, including development of chronic kidney disease and end-stage renal disease ...needing dialysis or transplantation.2 Few systematic efforts to manage (prevent, diagnose, and treat) AKI have been put in place and few resources have been allocated to inform health-care professionals and the public of the importance of AKI as a preventable and treatable disease.
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