Ghahramani Nasrollah, Shadrou Shahrouz, Hollenbeak Christopher
Department of Medicine, Pennsylvania State University College of Medicine, Hershey Medical Center, Hershey, PA 17033, USA.
Nephrology (Carlton). 2008 Oct;13(7):570-8. doi: 10.1111/j.1440-1797.2008.00966.x. Epub 2008 Jun 1.
Acute renal failure (ARF) still bears a poor prognosis with mortality rates up to 70% and the ideal form of renal replacement therapy (RRT) remains controversial. The purpose of this study was to conduct a systematic review and meta-analysis of all randomized controlled trials (RCT) to examine the effect of dialysis modality (IHD: Intermittent haemodialysis; CRRT: continuous renal replacement therapy) on survival of patients with ARF and to also study the effect of each modality on dialysis dependence (DD).
Using and combining two comprehensive search themes (ARF and RRT), we searched electronic databases from 1969 through September of 2007, supplemented by a manual review of abstracts from nephrology meetings and reference lists of review articles. All RCT comparing IHD with CRRT in adult patients with ARF and with explicit reporting of mortality were included. The primary outcome was the pooled estimate of the odds ratio (OR) of mortality for patients with ARF treated with CRRT versus IHD. The secondary outcome was OR of DD at time of discharge for surviving patients.
A total of 587 studies were identified, 554 of which were excluded on initial screening. Analysis of the nine RCT (1635 patients) showed an OR of 0.89 (0.63-1.24) for survival in patients on CRRT. Limiting the analysis to the seven RCT published after the year 2000, revealed an OR of 0.72 (0.58-0.90). The OR of all the studies before 2000 was 1.06 (95% CI 0.67-1.68), as compared with OR of 0.61 (95% CI 0.50-0.74) for studies post-2000. Four studies showed a significantly lower risk of DD among the CRRT group and none showed higher OR for DD. When analysis was limited to the RCT, the OR for DD was 1.07 (0.47-2.39), suggesting no difference in DD between the modalities.
Similar to previously reported meta-analyses, we did not find a significant effect of CRRT on the OR of survival. The progressive reduction in the OR of survival with CRRT relative to IHD might reflect progressive improvements in IHD. The OR of DD was not affected by mode of RRT. In conclusion, compared with IHD, CRRT does not offer an advantage with regards to survival or DD in ARF. Considering its cost and potential disadvantages, it is imperative to identify the subset of patients with ARF that would potentially derive maximum benefit from CRRT. This will require large, adequately powered studies with sufficient follow-up.
急性肾衰竭（ARF）的预后仍然很差，死亡率高达70%，理想的肾脏替代治疗（RRT）形式仍存在争议。本研究的目的是对所有随机对照试验（RCT）进行系统评价和荟萃分析，以检验透析方式（IHD：间歇性血液透析；CRRT：连续性肾脏替代治疗）对ARF患者生存率的影响，并研究每种方式对透析依赖（DD）的影响。
使用并结合两个全面的检索主题（ARF和RRT），我们检索了1969年至2007年9月的电子数据库，并辅以对肾脏病会议摘要和综述文章参考文献列表的人工查阅。纳入所有比较IHD与CRRT治疗成年ARF患者且明确报告死亡率的RCT。主要结局是CRRT治疗与IHD治疗的ARF患者死亡率的合并比值比（OR）估计值。次要结局是存活患者出院时DD的OR。
共识别出587项研究，其中554项在初步筛选时被排除。对9项RCT（1635例患者）的分析显示，CRRT治疗患者的生存OR为0.89（0.63 - 1.24）。将分析限于2000年后发表的7项RCT，显示OR为0.72（0.58 - 0.90）。2000年前所有研究的OR为1.06（95%CI 0.67 - 1.68），而2000年后研究的OR为0.61（95%CI 0.50 - 0.74）。4项研究显示CRRT组DD风险显著较低，且无研究显示DD的OR更高。当分析限于RCT时，DD的OR为1.07（0.47 - 2.39），表明两种方式在DD方面无差异。
与先前报道的荟萃分析相似，我们未发现CRRT对生存OR有显著影响。与IHD相比，CRRT生存OR的逐渐降低可能反映了IHD的逐渐改善。DD的OR不受RRT方式的影响。总之，与IHD相比，CRRT在ARF患者的生存或DD方面没有优势。考虑到其成本和潜在缺点，必须确定可能从CRRT中获得最大益处的ARF患者亚组。这将需要大型、有足够效力且随访充分的研究。
