Swartz R D, Bustami R T, Daley J M, Gillespie B W, Port F K
Department of Internal Medicine, Division of Nephrology, University of Michigan Health System, Ann Arbor, MI 48109-0364, USA.
Clin Nephrol. 2005 May;63(5):335-45. doi: 10.5414/cnp63335.
Mortality in severe acute renal failure (ARF) requiring renal replacement therapy (RRT) approximates 50% and varies with clinical severity. Continuous RRT (CRRT) has theoretical advantages over intermittent hemodialysis (IHD) for critical patients, but a survival advantage with CRRT is yet to be clearly demonstrated. To date, no prospective controlled trial has sufficiently answered this question, and the present prospective outcome study attempts to compare survival with CRRT versus that with IHD.
Multivariable Cox-proportional hazards regression was used to analyze the impact of RRT modality choice (CRRT vs. IHD) on in-hospital and 100-day mortality among ARF patients receiving RRT during 2000 and 2001 at University of Michigan, using an "intent-to-treat" analysis adjusted for multiple comorbidity and severity factors.
Overall in-hospital mortality before adjustment was 52%. Triage to CRRT (vs IHD) was associated with higher severity and unadjusted relative rate (RR) of in-hospital death (RR = 1.62, p = 0.001, n = 383). Adjustment for comorbidity and severity of illness reduced the RR of death for patients triaged to CRRT and suggested a possible survival advantage (RR = 0.81, p = 0.32). Analysis restricted to patients in intensive care for more than five days who received at least 48 hours of total RRT, showed the RR of in-hospital mortality with CRRT to be nearly 45% lower than IHD (RR = 0.56, n = 222), a difference in RR that indicates a strong trend for in-hospital mortality with borderline statistical significance (p = 0.069). Analysis of 100-day mortality also suggested a potential survival advantage for CRRT in all cohorts, particularly among patients in intensive care for more than five days who received at least 48 h of RRT (RR = 0.60, p = 0.062, n = 222).
Applying the present methodology to outcomes at a single tertiary medical center, CRRT may appear to afford a survival advantage for patients with severe ARF treated in the ICU. Unless and until a prospective controlled trial is realized, the present data suggest potential survival advantages of CRRT and support broader application of CRRT among such critically ill patients.
需要肾脏替代治疗（RRT）的严重急性肾衰竭（ARF）患者的死亡率约为50%，且因临床严重程度而异。对于重症患者，连续性肾脏替代治疗（CRRT）相较于间歇性血液透析（IHD）具有理论优势，但CRRT的生存优势尚未得到明确证实。迄今为止，尚无前瞻性对照试验充分回答这一问题，而本前瞻性结局研究试图比较CRRT与IHD的生存率。
采用多变量Cox比例风险回归分析RRT模式选择（CRRT与IHD）对2000年至2001年期间在密歇根大学接受RRT的ARF患者住院期间及100天死亡率的影响，使用“意向性治疗”分析，并针对多种合并症和严重程度因素进行调整。
调整前总体住院死亡率为52%。接受CRRT（相对于IHD）治疗的患者病情更严重，且未调整的住院死亡相对率（RR）更高（RR = 1.62，p = 0.001，n = 383）。对合并症和疾病严重程度进行调整后，接受CRRT治疗患者的死亡RR降低，并显示出可能的生存优势（RR = 0.81，p = 0.32）。对在重症监护病房（ICU）接受治疗超过五天且接受了至少48小时总RRT的患者进行分析，结果显示CRRT组的住院死亡率RR比IHD组低近45%（RR = 0.56，n = 222），RR的差异表明住院死亡率存在显著趋势，具有临界统计学意义（p = 0.069）。对100天死亡率的分析也表明，CRRT在所有队列中均具有潜在的生存优势，尤其是在ICU接受治疗超过五天且接受了至少48小时RRT的患者中（RR = 0.60，p = 0.062，n = 222）。
将本方法应用于单一三级医疗中心的结局研究时，CRRT似乎可为ICU中治疗的重症ARF患者带来生存优势。在进行前瞻性对照试验之前，目前的数据表明CRRT具有潜在的生存优势，并支持在这类重症患者中更广泛地应用CRRT。
