Cho Kerry C, Himmelfarb Jonathan, Paganini Emil, Ikizler T Alp, Soroko Sharon H, Mehta Ravindra L, Chertow Glenn M
Division of Nephrology, Department of Medicine, University of California San Francisco, San Francisco, CA 94118, USA.
J Am Soc Nephrol. 2006 Nov;17(11):3132-8. doi: 10.1681/ASN.2006030268. Epub 2006 Oct 4.
Among critically ill patients, acute kidney injury (AKI) requiring dialysis is associated with mortality rates generally in excess of 50%. Continuous renal replacement therapies (CRRT) often are recommended and widely used, although data to support its superiority over intermittent hemodialysis (IHD) are lacking. Data from the Program to Improve Care in Acute Renal Disease (PICARD), a multicenter observational study of AKI, were analyzed. Among 398 patients who required dialysis, the risk for death within 60 d was examined by assigned initial dialysis modality (CRRT [n = 206] versus IHD [n = 192]) using standard Kaplan-Meier product limit estimates, proportional hazards ("Cox") regression methods, and a propensity score approach to account for selection effects. Crude survival rates were lower for patients who were treated with CRRT than IHD (survival at 30 d 45 versus 58%; P = 0.006). Adjusted for age, hepatic failure, sepsis, thrombocytopenia, blood urea nitrogen, and serum creatinine and stratified by site, the relative risk for death associated with CRRT was 1.82 (95% confidence interval 1.26 to 2.62). Further adjustment for the propensity score did not materially alter the association (relative risk 1.92; 95% confidence interval 1.28 to 2.89). Among critically ill patients with AKI, CRRT was associated with increased mortality. Although the results could reflect residual confounding by severity of illness, these data provide no evidence for a survival benefit afforded by CRRT. Larger, prospective, randomized clinical trials to compare CRRT and IHD in severe AKI are needed.
在危重症患者中，需要透析的急性肾损伤（AKI）患者的死亡率通常超过50%。尽管缺乏支持其优于间歇性血液透析（IHD）的数据，但连续肾脏替代疗法（CRRT）仍常被推荐并广泛使用。对急性肾疾病改善护理计划（PICARD）这一多中心AKI观察性研究的数据进行了分析。在398例需要透析的患者中，采用标准的Kaplan-Meier乘积限估计法、比例风险（“Cox”）回归方法以及倾向评分法来考虑选择效应，通过指定的初始透析方式（CRRT [n = 206] 对比IHD [n = 192]）来检查60天内的死亡风险。接受CRRT治疗的患者的粗生存率低于IHD治疗的患者（30天时的生存率分别为45% 和58%；P = 0.006）。在对年龄、肝衰竭、脓毒症、血小板减少症、血尿素氮和血清肌酐进行校正并按地点分层后，与CRRT相关的死亡相对风险为1.82（95%置信区间为1.26至2.62）。对倾向评分进行进一步校正并没有实质性改变这种关联（相对风险为1.92；95%置信区间为1.28至2.89）。在患有AKI的危重症患者中，CRRT与死亡率增加相关。尽管结果可能反映了疾病严重程度导致的残余混杂因素，但这些数据并未提供CRRT能带来生存益处的证据。需要开展更大规模的前瞻性随机临床试验来比较严重AKI患者中CRRT和IHD的效果。
