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

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 3117 subjects were included. Compared with the non-CRRT group, CRRT was associated with reduced 28-day mortality (RR: 0.42, 95% CI: 0.30–0.58, 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: CRRT may be associated with reduced 28-day and hospital mortality rates, a lower incidence of cardiovascular events, and shorter intensive care unit and in-hospital stays in patients with SA-AKI than standard therapy alone. However, the overall certainty of evidence assessed using the Grading of Recommendations Assessment, Development and Evaluation approach was low to very low, primarily because of limited sample sizes, methodological bias, and clinical heterogeneity among the included studies. Therefore, the findings should be interpreted with caution. Future high-quality, multicenter international randomized controlled trials with standardized CRRT protocols and longer follow-up durations are warranted to validate these results and optimize the clinical application of CRRT in SA-AKI.