Pannu Neesh, Klarenbach Scott, Wiebe Natasha, Manns Braden, Tonelli Marcello
Department of Medicine, University of Alberta, Edmonton, Alberta, Canada.
JAMA. 2008 Feb 20;299(7):793-805. doi: 10.1001/jama.299.7.793.
Acute renal failure requiring dialytic support is associated with a high risk of mortality and substantial morbidity.
To summarize current evidence guiding provision of dialysis for patients with acute renal failure, to make recommendations for management, and to identify areas in which additional research is needed.
Systematic searches of peer-reviewed publications in MEDLINE, EMBASE, and All EBM Reviews through October 2007.
Randomized controlled trials (RCTs) and prospective cohort studies studying dialytic support in adults with acute renal failure that reported the incidence of clinical outcomes such as mortality, length of stay, need for chronic dialysis, or development of hypotension.
Quality was independently assessed by 2 reviewers using the Jadad score (RCTs) and the Downs and Black checklist (cohort studies). A single reviewer extracted data, which were independently verified by a second reviewer. Results of RCTs were pooled using a random-effects model.
From 173 retrieved articles, 30 RCTs and 8 prospective cohort studies were eligible. No conclusions could be drawn about optimal indications for or timing of renal replacement. Available data comparing continuous renal replacement therapy (CRRT) with intermittent hemodialysis demonstrated no clinically relevant difference between modalities, including for all-cause mortality (relative risk [RR], 1.10; 95% confidence interval [CI], 0.99-1.23; I2 = 0%) or for the requirement for chronic dialysis treatment in survivors (RR, 0.91; 95% CI, 0.56-1.49; I2 = 0%). For patients treated with CRRT, limited data suggest that bicarbonate may be preferable to other forms of dialysate alkali and that citrate infusion may be an alternative to systemic anticoagulation in patients at high risk of bleeding. Among patients treated with continuous venovenous hemofiltration (CVVHF), the risk of death was lower at doses of 35 mL/kg per hour (RR of death compared with doses of 20 mL/kg per hour, 0.74; 95% CI, 0.63-0.88). The use of unsubstituted cellulosic membranes should be avoided in intermittent hemodialysis (RR of death compared with biocompatible membranes, 1.23; 95% CI, 1.01-1.50).
Based on current data, intermittent hemodialysis and CRRT appear to lead to similar clinical outcomes for patients with ARF. If CVVHF is used, a dose of 35 mL/kg per hour should be provided. Given the paucity of good-quality evidence in this important area, additional large randomized trials are needed to evaluate clinically important outcomes.
需要透析支持的急性肾衰竭与高死亡率和严重发病率相关。
总结指导急性肾衰竭患者透析治疗的当前证据，提出管理建议，并确定需要进一步研究的领域。
截至2007年10月，对MEDLINE、EMBASE和所有循证医学综述中的同行评审出版物进行系统检索。
研究急性肾衰竭成人透析支持的随机对照试验（RCT）和前瞻性队列研究，报告了死亡率、住院时间、慢性透析需求或低血压发生等临床结局的发生率。
由2名评审员分别使用Jadad评分（RCT）和Downs及Black清单（队列研究）独立评估质量。由一名评审员提取数据，另一名评审员进行独立核实。RCT的结果使用随机效应模型进行汇总。
从检索到的173篇文章中，30项RCT和8项前瞻性队列研究符合要求。关于肾脏替代的最佳指征或时机无法得出结论。比较持续肾脏替代治疗（CRRT）和间歇性血液透析的现有数据表明，两种方式在临床上没有显著差异，包括全因死亡率（相对风险[RR]，1.10；95%置信区间[CI]，0.99 - 1.23；I² = 0%）或幸存者慢性透析治疗需求（RR，0.91；95% CI，0.56 - 1.49；I² = 0%）。对于接受CRRT治疗的患者，有限的数据表明，碳酸氢盐可能比其他形式的透析液碱更可取，对于出血风险高的患者，柠檬酸盐输注可能是全身抗凝的替代方法。在接受持续静脉 - 静脉血液滤过（CVVHF）治疗的患者中，每小时35 mL/kg剂量时死亡风险较低（与每小时20 mL/kg剂量相比，死亡RR为0.74；95% CI，0.63 - 0.88）。间歇性血液透析应避免使用未取代的纤维素膜（与生物相容性膜相比，死亡RR为1.23；95% CI，1.01 - 1.50）。
基于目前的数据，间歇性血液透析和CRRT对急性肾衰竭患者似乎产生相似的临床结局。如果使用CVVHF，应提供每小时35 mL/kg的剂量。鉴于这一重要领域高质量证据匮乏，需要更多大型随机试验来评估临床上重要的结局。
