Faulhaber-Walter Robert, Hafer Carsten, Jahr Nicole, Vahlbruch Jutta, Hoy Ludwig, Haller Hermann, Fliser Danilo, Kielstein Jan T
Department of Internal Medicine, Hannover Medical School, Hannover, Germany.
Nephrol Dial Transplant. 2009 Jul;24(7):2179-86. doi: 10.1093/ndt/gfp035. Epub 2009 Feb 13.
Increasing the dose of renal replacement therapy has been shown to improve survival in critically ill patients with acute kidney injury (AKI) in several smaller European trials. However, a very recent large multicentre trial in the USA could not detect an effect of dose of renal replacement therapy on mortality. Based on those studies, it is not known whether a further increase in dialysis dose above and beyond the currently employed doses would improve survival in patients with AKI. We therefore aimed to assess mortality and renal recovery of patients with AKI receiving either standard (SED) or intensified extended dialysis (IED) therapy in the intensive care unit.
A prospective randomized parallel group study was conducted in seven intensive care units of a tertiary university hospital. Pre-existing chronic kidney disease was an exclusion criterion. A total of 156 patients (570 screened) with AKI requiring renal replacement therapy were randomly assigned to receive standard dialysis [dosed to maintain plasma urea levels between 120 and 150 mg/dL (20-25 mmol/L)] or intensified dialysis [dosed to maintain plasma urea levels <90 mg/dL (<15 mmol/L)]. Outcome measures were survival at Day 14 (primary) and survival and renal recovery at Day 28 (secondary) after initiation of renal replacement therapy.
Treatment intensity differed significantly (P < 0.01 for plasma urea and administered dose). No differences between intensified and standard treatment were seen for survival by Day 14 (70.4% versus 70.7%) or Day 28 (55.6% versus 61.3%), or for renal recovery amongst the survivors by Day 28 (60.0% versus 63.0%).
Although this study cannot deliver a definitive answer, it suggests that increasing the dose of extended dialysis above the currently recommended dose might neither reduce mortality nor improve renal recovery in critically ill patients, mainly septic patients, with AKI.
在欧洲的几项规模较小的试验中，已表明增加肾脏替代治疗的剂量可提高急性肾损伤（AKI）重症患者的生存率。然而，美国最近一项大型多中心试验未能发现肾脏替代治疗剂量对死亡率有影响。基于这些研究，目前尚不清楚在当前使用剂量之上进一步增加透析剂量是否会改善AKI患者的生存率。因此，我们旨在评估在重症监护病房接受标准（SED）或强化延长透析（IED）治疗的AKI患者的死亡率和肾脏恢复情况。
在一所三级大学医院的七个重症监护病房进行了一项前瞻性随机平行组研究。排除已有慢性肾脏病的患者。共有156例（筛查了570例）需要肾脏替代治疗的AKI患者被随机分配接受标准透析[剂量设定为维持血浆尿素水平在120至150mg/dL（20 - 25mmol/L）之间]或强化透析[剂量设定为维持血浆尿素水平<90mg/dL（<15mmol/L）]。观察指标为开始肾脏替代治疗后第14天的生存率（主要指标）以及第28天的生存率和肾脏恢复情况（次要指标）。
治疗强度有显著差异（血浆尿素和给药剂量的P<0.01）。强化治疗和标准治疗在第14天的生存率（70.4%对70.7%）或第28天的生存率（55.6%对61.3%）方面，以及在第28天幸存者中的肾脏恢复情况（60.0%对63.0%）方面均未观察到差异。
尽管本研究无法给出明确答案，但它表明在当前推荐剂量之上增加延长透析剂量可能既不会降低AKI重症患者（主要是脓毒症患者）的死亡率，也不会改善其肾脏恢复情况。
