Chao DC, Scheinhorn DJ, Stearn-Hassenpflug M
Barlow Respiratory Hospital, Barlow Respiratory Research Center, 2000 Stadium Way, Los Angeles, CA 90026-2696, USA.
Crit Care. 1997;1(3):101-104. doi: 10.1186/cc112.
In the intensive care unit (ICU) setting, the combination of mechanical ventilation and renal replacement therapy (RRT) has been associated with prolonged length of hospital stay, high cost of care and poor outcome. We gathered outcome data on patients who had severe renal dysfunction on transfer to our regional weaning center (RWC) for attempted weaning from prolonged mechanical ventilation (PMV). We screened the admission laboratory values of 1077 patients transferred to our RWC over an 8-year period. We reviewed the medical records of patients with serum creatinine > 2.5 mg/dl. RESULTS: Sixty-three patients met screening criteria and 40 patients were on RRT at the time of transfer. Eighteen patients had begun chronic RRT at least 2 months prior to admission to the transferring hospital for their current illness. Twenty-two patients had RRT initiated at the transferring hospital. Ten patients had RRT initiated at the RWC; eight patients had improvement or resolution of azotemia at our facility. RRT was withheld at patient/family request in five patients with progressive renal failure. None of the 50 patients who received RRT recovered renal function during treatment at our RWC. Intermittent hemodialysis was the standard RRT at the RWC. Duration of mechanical ventilation prior to transfer to the RWC was 49.7 +/- 33.5 days (mean +/- SD).Outcome of weaning attempts in the 63 patients was as follows: 13% weaned, 3% failed to wean and 84% died. These outcomes were significantly worse (P<0.001) than those in the 1014 patients whose admission serum creatinine was </= 2.5 mg/dl (58% weaned, 15% failed to wean, 27% died). The five patients in whom RRT was withheld were predominantly in progressive multisystem organ failure, and were unlikely to have survived regardless of RRT. From the study cohort, only one of the 10 patients discharged alive returned home, in contrast to 42% of the control group. No patient with severe renal dysfunction survived to 1 year post-discharge, compared to a 1-year survival of 38% in the control group (P = 0.029). Only four of the 10 patients survived more than 1 month, with the longest survival being 122 days. CONCLUSIONS: Patients who require PMV and RRT have a very poor prognosis. The small number of patients with renal insufficiency not requiring RRT had a more favorable hospital outcome and mortality, but long-term survival remained poor.
在重症监护病房（ICU）环境中，机械通气与肾脏替代治疗（RRT）的联合应用与住院时间延长、护理成本高昂及预后不良相关。我们收集了转至我们区域撤机中心（RWC）试图从长期机械通气（PMV）撤机的严重肾功能不全患者的预后数据。我们筛查了8年间转至我们RWC的1077例患者的入院实验室值。我们回顾了血清肌酐>2.5mg/dl患者的病历。结果：63例患者符合筛查标准，40例患者在转院时接受RRT治疗。18例患者在因当前疾病入住转诊医院前至少2个月已开始慢性RRT治疗。22例患者在转诊医院开始RRT治疗。10例患者在RWC开始RRT治疗；8例患者在我们的机构中氮质血症有所改善或消退。5例进行性肾衰竭患者因患者/家属要求未进行RRT治疗。在我们RWC接受治疗的50例接受RRT治疗的患者中，无一例肾功能恢复。间歇性血液透析是RWC的标准RRT治疗方式。转至RWC前机械通气时间为49.7±33.5天（平均值±标准差）。63例患者撤机尝试的结果如下：13%成功撤机，3%撤机失败，84%死亡。这些结果明显差于（P<0.001）入院血清肌酐≤2.5mg/dl的1014例患者（58%成功撤机，15%撤机失败，27%死亡）。未进行RRT治疗的5例患者主要处于进行性多系统器官衰竭状态，无论是否进行RRT治疗都不太可能存活。在研究队列中，10例存活出院的患者中只有1例回家，而对照组为42%。与对照组1年生存率38%相比，严重肾功能不全患者出院后无1例存活至1年（P = 0.029）。10例患者中只有4例存活超过1个月，最长存活时间为122天。结论：需要PMV和RRT治疗的患者预后非常差。少数不需要RRT治疗的肾功能不全患者医院结局和死亡率更有利，但长期生存率仍然很低。
