Table 1.
GRADE evaluation of interventions for acute kidney injury
| Important outcomes | Kidney injury, mortality, adverse effects | ||||||||
| Number of studies (participants) | Outcome | Comparison | Type of evidence | Quality | Consistency | Directness | Effect size | GRADE | Comment |
| What are the effects of interventions to prevent acute kidney injury in people at high risk? | |||||||||
| 31 (5146) [22] | Kidney injury | Low-osmolality contrast media v high-osmolality contrast media | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 2 (365)[23] [24] | Kidney injury | Intravenous sodium chloride 0.9% v oral fluids | 4 | 0 | −1 | 0 | 0 | Moderate | Consistency point deducted for conflicting results |
| 1 (1620)[26] | Kidney injury | Sodium chloride 0.9% v sodium chloride 0.45% | 4 | 0 | 0 | 0 | 0 | High | |
| 1 (45)[27] | Kidney injury | Sodium chloride 0.45% v restricted fluids | 4 | −2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 1 (36)[28] | Kidney injury | Inpatient v outpatient fluid regimens | 4 | −2 | 0 | −2 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Directness points deducted for differences in amount of fluids administered and uncertainty about clinical relevance of outcome measured |
| 28 (3570)[31] [32] [33] [34] | Kidney injury | Acetylcysteine v control in the prevention of contrast nephropathy | 4 | 0 | −1 | 0 | 0 | Moderate | Consistency point deducted for heterogeneity among RCTs |
| 10 (1193 at most)[35] | Mortality | Acetylcysteine v placebo in the prevention of perioperative acute renal failure | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 13 (1339 at most)[35] [36] | Kidney injury | Acetylcysteine v placebo in the prevention of perioperative acute renal failure | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 1 (142)[37] | Kidney injury | Acetylcysteine v placebo in the prevention of acute renal failure after hypotension | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 29 (3270)[39] [40] [41] [42] [43] | Kidney injury | Iso-osmolar contrast media v low-osmolar contrast media | 4 | −1 | −1 | −1 | 0 | Very low | Quality point deducted for incomplete reporting of results. Consistency point deducted for conflicting results. Directness point deducted for not using standardised volumes of contrast media or fluid regimens |
| 4 (803)[45] [46] | Kidney injury | Single-dose aminoglycosides v multiple doses | 4 | −1 | −1 | 0 | 0 | Low | Quality point deducted for incomplete reporting of results. Consistency point deducted for different results for people with different disease severities |
| 20 (26,984)[47] [48] [49] [50] | Kidney injury | Sodium bicarbonate v sodium chloride for the prevention of contrast nephropathy | 4 | −1 | −1 | −1 | 0 | Very low | Quality point deducted for the inclusion of underpowered trials. Consistency point deducted for conflicting results. Directness point deducted for the presence of heterogeneity among trials |
| 7 (1334)[47] | Mortality | Sodium bicarbonate v sodium chloride for the prevention of contrast nephropathy | 4 | −1 | 0 | −1 | 0 | Low | Quality point deducted for the inclusion of underpowered trials. Directness point deducted for heterogeneity among trials |
| 1 (100)[51] | Kidney injury | Sodium bicarbonate v sodium chloride for the prevention of acute kidney injury after cardiothoracic surgery | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 3 (770)[56] [57] [58] | Kidney injury | Fenoldopam v placebo | 4 | 0 | 0 | 0 | 0 | High | |
| 3 (770)[56] [57] [58] | Mortality | Fenoldopam v placebo | 4 | 0 | 0 | 0 | 0 | High | |
| 2 (180)[59] [60] | Kidney injury | Fenoldopam v dopamine | 4 | −2 | −1 | 0 | 0 | Very low | Quality points deducted for sparse data and incomplete reporting of results. Consistency point deducted for conflicting results |
| 11 (1094)[61] | Kidney injury | Fenoldopam v other treatments or control | 4 | −2 | −1 | −1 | 0 | Very low | Quality points deducted for incomplete reporting of results and methodological weaknesses. Consistency point deducted for heterogeneity among RCTs. Directness point deducted for heterogeneous combined control |
| 3 (168)[25] [66] [67] | Kidney injury | Mannitol with or without fluids v fluids | 4 | −1 | 0 | −1 | 0 | Low | Quality point deducted for sparse data. Directness point deducted for multiple comparisons |
| 7 (836 at most)[68] [69] | Kidney injury | Renal replacement therapy (haemofiltration) v standard therapy | 4 | −2 | −1 | 0 | 0 | Very low | Quality points deducted for methodological weaknesses and incomplete reporting of results. Consistency point deducted for conflicting results across studies |
| 9 (585)[72] | Kidney injury | Theophylline or aminophylline v control in radiocontrast-induced nephropathy | 4 | −3 | 0 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results, uncertainty about hydration status of people receiving radiocontrast agent, and for uncertainty about heterogeneity among studies |
| 1 (56)[73] | Kidney injury | Theophylline v sodium chloride 0.9% after CABG | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (210)[74] | Kidney injury | Calcium channel blockers v placebo in people receiving live or cadaveric kidney transplant | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 7 (349)[75] | Kidney injury | Calcium channel blockers v no calcium channel blockers in people receiving cadaveric kidney transplant | 4 | −2 | −1 | 0 | 0 | Very Low | Quality points deducted for incomplete reporting of results and for not reporting loss to follow-up or duration. Consistency point deducted for heterogeneity among RCTs |
| 2 (132)[76] [77] | Kidney injury | Calcium channel blockers v placebo in people undergoing abdominal surgery | 4 | −2 | 0 | 0 | 0 | Low | Quality points deducted for sparse data and incomplete reporting of results |
| 5 (284)[75] | Mortality | Calcium channel blockers v no calcium channel blockers in people receiving cadaveric kidney transplant | 4 | −2 | −1 | 0 | 0 | Very Low | Quality points deducted for incomplete reporting of results and for not reporting loss to follow-up or treatment duration. Consistency point deducted for heterogeneity among RCTs |
| at least 10 RCTs (at least 618 people) [78] [79] [80] | Kidney injury | Dopamine v placebo | 4 | 0 | 0 | 0 | 0 | High | |
| 12 (832)[78] [80] | Mortality | Dopamine v placebo | 4 | 0 | 0 | 0 | 0 | High | |
| 4 (297)[83] [84] | Kidney injury | Loop diuretics v fluids alone | 4 | 0 | 0 | −1 | 0 | Moderate | Directness point deducted for differences in treatment protocols |
| 2 (202)[83] | Mortality | Loop diuretics v fluids alone | 4 | 0 | 0 | −1 | 0 | Moderate | Directness point deducted for differences in treatment protocols |
| 11 (818)[86] [87] | Kidney injury | Natriuretic peptides for the prevention of acute kidney injury v other treatments | 4 | 0 | 0 | 0 | 0 | High | |
| 10 (794)[86] [87] | Mortality | Natriuretic peptides for the prevention of acute kidney injury v other treatments | 4 | 0 | 0 | 0 | 0 | High | |
| 13 (1532)[88] [89] [90] | Kidney injury | Natriuretic peptides for the prevention of acute kidney injury after cardiothoracic surgery v other treatments | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 2 (598)[89] [90] | Mortality | Natriuretic peptides for the prevention of acute kidney injury after cardiothroacic surgery v other treatments | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| What are the effects of treatments for critically ill people with acute kidney injury? | |||||||||
| 2 (2585)[95] | Mortality | Standard-dose continuous renal replacement therapy v high-dose continuous renal replacement therapy | 4 | 0 | 0 | 0 | 0 | High | |
| 10 (1403 max)[97] [98] | Kidney injury | Continuous renal replacement therapy v intermittent renal replacement therapy | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 10 (1403 max)[97] [98] [99] | Mortality | Continuous renal replacement therapy v intermittent renal replacement therapy | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 1 (360)[118] | Mortality | Renal replacement therapy (intermittent haemodialysis) v continuous veno-venous haemodiafiltration | 4 | 0 | 0 | −1 | 0 | Moderate | Directness point deducted for uncertainty about applicability to usual practice |
| 18 studies at most (1967)[108] [107] | Mortality | Dialysis membranes (synthetic) v cellulose-based | 4 | −3 | −1 | 0 | 0 | Very low | Quality points deducted for incomplete reporting of results, methodological weaknesses, and for including non-randomised trials and observational studies. Consistency point deducted for conflicting results |
| at least 2 RCTs (at least 422 people)[83] [110] | Kidney injury | Loop diuretics v control | 4 | −3 | 0 | 0 | 0 | Very low | Quality points deducted for poor reporting and methodological weaknesses |
| 5 (at least 574 people)[83] [110] | Mortality | Loop diuretics v control | 4 | −3 | 0 | 0 | 0 | Very low | Quality points deducted for poor reporting and methodological weaknesses |
| 10 (618)[78] | Kidney injury | Dopamine v placebo | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for inclusion of observational studies |
| 1 RCT + 11 trials (832)[78] [80] | Mortality | Dopamine v placebo | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for inclusion of observational studies |
| 8 (1043)[86] | Kidney injury | Natriuretic peptides v placebo | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for incomplete reporting of results |
| 8 (354)[97] [115] | Kidney injury | Early v late renal replacement therapy | 4 | −1 | −1 | 0 | 0 | Low | Quality point deducted for inclusion of observational studies. Consistency point deducted for conflicting results |
| 26 (3715)[97] [115] [116] | Mortality | Early v late renal replacement therapy | 4 | −2 | −2 | 0 | 0 | Very low | Quality points deducted for inclusion of observational studies and heterogeneity among pooled trials. Consistency points deducted for conflicting results and different results when sensitivity analyses were performed |
| 1 (64)[97] | Kidney injury | Extended daily dialysis v continuous renal replacement therapy | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
| 1 (64) [97] | Mortality | Extended daily dialysis v continuous renal replacement therapy | 4 | −1 | 0 | 0 | 0 | Moderate | Quality point deducted for sparse data |
Type of evidence: 4 = RCT; 2 = Observational. Consistency: similarity of results across studies.Directness: generalisability of population or outcomes.Effect size: based on relative risk or odds ratio.