The role of continuous renal replacement therapy in sepsis-associated acute kidney injury: a systematic review and meta-analysis

Abstract

Background: Continuous renal replacement therapy (CRRT) is commonly used to manage sepsis-associated acute kidney injury (SA-AKI) as a form of extracorporeal blood purification. However, the current consensus report from the 28th Acute Disease Quality Initiative workgroup does not provide explicit recommendations for the use of CRRT in SA-AKI, because of insufficient high-quality evidence regarding its efficacy. This study aimed to evaluate whether CRRT provides clinical benefits compared with non-CRRT therapy in patients with SA-AKI.
Methods: All randomized controlled trials published up to October 11, 2025, in 9 Chinese and English databases were reviewed and included in the study. A meta-analysis was performed on the experimental group (CRRT group) and control group (non-CRRT group) using risk ratios (RRs), weighted mean differences (WMDs), and 95% confidence intervals (CIs). The certainty of evidence for each outcome was evaluated using the Grading of Recommendations Assessment, Development and Evaluation approach.
Results: A total of 37 studies involving 3120 subjects were included. Compared with the non-CRRT group, CRRT was associated with reduced 28-day mortality (RR: 0.46, 95% CI: 0.34–0.61, P < 0.01), hospital mortality (RR: 0.39, 95% CI: 0.28–0.54, P < 0.01), and incidence of cardiovascular events (RR: 0.39, 95% CI: 0.28–0.55, P < 0.01). CRRT was also associated with shorter intensive care unit length of stay (WMD: -3.97, 95% CI: -4.71 to -3.22, P < 0.01) and in-hospital length of stay (WMD: -4.51, 95% CI: -5.51 to -3.51, P < 0.01).
Conclusion: The pooled estimates from the included studies favored CRRT with respect to 28-day mortality, hospital mortality, incidence of cardiovascular events, ICU length of stay, and in-hospital length of stay; however, the certainty of evidence was low to very low because of methodological limitations, heterogeneity in CRRT definitions and treatment protocols, small study sizes, and limited geographic generalizability. These findings should not be interpreted as establishing a routine clinical benefit of CRRT in SA-AKI or as supporting CRRT initiation in patients without standard indications for kidney replacement therapy. Further independent, prospectively registered, multicenter randomized controlled trials with standardized CRRT protocols are needed to confirm these findings.

Keywords

Acute kidney injury / Continuous renal replacement therapy / Meta-analysis / Sepsis

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