Gangji A S, Rabbat C G, Margetts P J
Department of Medicine, McMaster University, Hamilton, Ontario, Canada.
Clin Nephrol. 2005 Apr;63(4):267-75. doi: 10.5414/cnp63267.
Acute renal failure in the intensive care setting is common and impacts on patient's outcome. Continuous hemodialysis or hemofiltration offers theoretical benefit for patients with acute renal failure, but the clinical benefit has not been demonstrated in randomized trials. ICU patients with acute renal failure are a heterogeneous population and we hypothesize that patients with increased illness severity would benefit from continuous renal replacement therapy.
From a comprehensive ICU database, we identified patients with acute renal failure exposed to continuous or intermittent renal replacement therapy. We a priori identified a subgroup of patients with multiple organ dysfunction syndrome, then used survival analysis to assess the effect of dialysis modality in the overall acute renal failure population and in the subgroup with increased illness severity.
We identified 66 patients treated with intermittent and 36 patients treated with continuous renal replacement therapy. Patients with severe illness were preferentially selected for treatment with continuous dialysis (p = 0.01). Overall, there was no significant difference in survival between patients treated with intermittent or continuous dialysis. The relative risk of in-hospital mortality was significantly decreased in patients with multiple organ dysfunction syndrome (relative risk = 0.42+/-0.22, p = 0.027) treated with continuous therapy as compared with intermittent therapy. Among the survivors, continuous dialysis did not appear to hasten the return of renal function.
This retrospective study suggests that continuous dialysis may be beneficial in a subgroup of ICU patients with multiple organ dysfunction syndrome or severe sepsis. Further randomized trials of dialysis modality should, if possible, concentrate on this population.
重症监护环境下的急性肾衰竭很常见，且会影响患者的预后。连续性血液透析或血液滤过对急性肾衰竭患者理论上有益，但随机试验尚未证实其临床益处。急性肾衰竭的重症监护病房（ICU）患者是一个异质性群体，我们推测病情严重程度增加的患者将从连续性肾脏替代治疗中获益。
从一个全面的ICU数据库中，我们识别出接受连续性或间歇性肾脏替代治疗的急性肾衰竭患者。我们预先确定了一个多器官功能障碍综合征患者亚组，然后使用生存分析来评估透析方式对总体急性肾衰竭人群以及病情严重程度增加的亚组的影响。
我们识别出66例接受间歇性治疗的患者和36例接受连续性肾脏替代治疗的患者。病情严重的患者被优先选择接受连续性透析治疗（p = 0.01）。总体而言，接受间歇性或连续性透析治疗的患者生存率无显著差异。与间歇性治疗相比，接受连续性治疗的多器官功能障碍综合征患者（相对风险 = 0.42±0.22，p = 0.027）院内死亡的相对风险显著降低。在幸存者中，连续性透析似乎并未加速肾功能的恢复。
这项回顾性研究表明，连续性透析可能对患有多器官功能障碍综合征或严重脓毒症的ICU患者亚组有益。如果可能的话，进一步的透析方式随机试验应集中在这一人群。
