Liu Kathleen D, 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, USA.
Clin J Am Soc Nephrol. 2006 Sep;1(5):915-9. doi: 10.2215/CJN.01430406. Epub 2006 Jul 6.
Among critically ill patients, acute kidney injury (AKI) is a relatively common complication that is associated with an increased risk for death and other complications. To date, no treatment has been developed to prevent or attenuate established AKI. Dialysis often is required, but the optimal timing of initiation of dialysis is unknown. Data from the Program to Improve Care in Acute Renal Disease (PICARD), a multicenter observational study of AKI, were analyzed. Among 243 patients who did not have chronic kidney disease and who required dialysis for severe AKI, we examined the risk for death within 60 d from the diagnosis of AKI by the blood urea nitrogen (BUN) concentration at the start of dialysis (BUN < or = 76 mg/dl in the low degree of azotemia group [n = 122] versus BUN > 76 mg/dl in the high degree of azotemia group [n = 121]). Standard Kaplan-Meier product limit estimates, proportional hazards (Cox) regression methods, and a propensity score approach were used to account for selection effects. Crude survival rates were slightly lower for patients who started dialysis at higher BUN concentrations, despite a lesser burden of organ system failure. Adjusted for age, hepatic failure, sepsis, thrombocytopenia, and serum creatinine and stratified by site and initial dialysis modality, the relative risk for death that was associated with initiation of dialysis at a higher BUN was 1.85 (95% confidence interval 1.16 to 2.96). Further adjustment for the propensity score did not materially alter the association (relative risk 1.97; 95% confidence interval 1.21 to 3.20). Among critically ill patients with AKI, initiation of dialysis at higher BUN concentrations was associated with an increased risk for death. Although the results could reflect residual confounding by severity of illness, they provide a rationale for prospective testing of alternative dialysis initiation strategies in critically ill patients with severe AKI.
在重症患者中，急性肾损伤（AKI）是一种相对常见的并发症，与死亡风险及其他并发症的增加相关。迄今为止，尚未开发出预防或减轻已发生的AKI的治疗方法。通常需要进行透析，但开始透析的最佳时机尚不清楚。对急性肾疾病改善护理计划（PICARD）的数据进行了分析，该计划是一项关于AKI的多中心观察性研究。在243例无慢性肾脏病且因严重AKI需要透析的患者中，我们根据透析开始时的血尿素氮（BUN）浓度，研究了从AKI诊断起60天内的死亡风险（低氮质血症组[n = 122]的BUN≤76mg/dl，而高氮质血症组[n = 121]的BUN>76mg/dl）。采用标准的Kaplan-Meier乘积限估计法、比例风险（Cox）回归方法和倾向评分法来考虑选择效应。尽管器官系统衰竭负担较轻，但BUN浓度较高时开始透析的患者的粗生存率略低。在调整了年龄、肝功能衰竭、脓毒症、血小板减少症和血清肌酐，并按地点和初始透析方式分层后，与在较高BUN水平开始透析相关的死亡相对风险为1.85（95%置信区间1.16至2.96）。进一步调整倾向评分并没有实质性改变这种关联（相对风险1.97；95%置信区间1.21至3.20）。在患有AKI的重症患者中，在较高BUN浓度时开始透析与死亡风险增加相关。尽管结果可能反映了疾病严重程度造成的残余混杂，但它们为在患有严重AKI的重症患者中对替代透析起始策略进行前瞻性测试提供了理论依据。
