Department of Intensive Care, Austin Health, Heidelberg, Australia.
Nephrol Dial Transplant. 2012 Mar;27(3):947-52. doi: 10.1093/ndt/gfr501. Epub 2011 Sep 8.
Only a proportion of critically ill patients with severe [RIFLE (Risk, Injury, Failure, Loss, End-stage renal disease) criteria, class-F] acute kidney injury (AKI) appear to receive renal replacement therapy (RRT). The aim of this study was to study the characteristics and outcome of patients with severe (RIFLE-F) AKI who did not receive RRT.
We identified all consecutive patients admitted to our institution that developed RIFLE-F AKI by creatinine criteria over a 3-year period and did not receive RRT, and compared their characteristics and outcomes with those of RIFLE-F RRT-treated patients.
Within the study period, 20,126 patients were admitted to our institution for >24 h. Among them, 2949 were admitted to the intensive care unit (ICU) and 195 developed RIFLE-F AKI. Of these, 90 received RRT (RRT patients) and 105 did not (no-RRT patients). Compared with RRT patients, no-RRT patients were similar in terms of age, gender and ward of origin. However, they had a shorter median ICU stay (2.7 versus 7.9 days; P < 0.001), required less mechanical ventilation (56.2 versus 70%; P < 0.05) and had a lower mean Acute Physiology and Chronic Health Evaluation III score (82.7 versus 86.7; P < 0.05). The two main reasons these patients did not receive RRT were limitations of medical therapy (LOMT) orders in 41 (39%) cases and expected renal functional improvement in 59 (56.2%). Mortality in no-RRT patients was 58.1% compared with 55.5% in the RRT group (P = 0.72). After exclusion of LOMT patients, the mortality of the no-RRT group, although lower than that of the RRT group, remained high (30.5 versus 55%; P < 0.001). Most of these deaths occurred after ICU discharge and appeared secondary to underlying chronic diseases or recurrence of the initial insult.
After exclusion of LOMT patients, about a third of critically ill patients with severe (RIFLE-F) AKI did not receive RRT. A third of these patients died in hospital. The timing of the deaths and their underlying causes do not suggest that a broader application of RRT would have changed patient outcomes.
只有一部分患有严重 [RIFLE（风险、损伤、衰竭、丧失、终末期肾病）标准，F 级] 急性肾损伤（AKI）的危重病患者似乎接受了肾脏替代治疗（RRT）。本研究的目的是研究未接受 RRT 的严重（RIFLE-F）AKI 患者的特征和结局。
我们确定了在 3 年期间通过肌酐标准在我院住院并发展为 RIFLE-F AKI 但未接受 RRT 的所有连续患者，并将他们的特征和结局与接受 RIFLE-F RRT 治疗的患者进行比较。
在研究期间，我院共收治 20126 例住院时间超过 24 小时的患者。其中 2949 例收住 ICU，195 例发生 RIFLE-F AKI。其中 90 例接受 RRT（RRT 患者），105 例未接受（无 RRT 患者）。与 RRT 患者相比，无 RRT 患者在年龄、性别和病房来源方面相似。然而，他们的 ICU 中位住院时间更短（2.7 天与 7.9 天；P<0.001），机械通气需求更少（56.2%与 70%；P<0.05），平均急性生理学和慢性健康评估 III 评分较低（82.7 与 86.7；P<0.05）。这些患者未接受 RRT 的两个主要原因是 41 例（39%）存在限制医疗治疗（LOMT）医嘱和 59 例（56.2%）预期肾功能改善。无 RRT 患者的死亡率为 58.1%，而 RRT 组为 55.5%（P=0.72）。排除 LOMT 患者后，无 RRT 组的死亡率虽然低于 RRT 组，但仍较高（30.5%与 55%；P<0.001）。这些死亡大多发生在 ICU 出院后，似乎继发于基础慢性疾病或初始损伤的复发。
排除 LOMT 患者后，约三分之一的严重（RIFLE-F）AKI 危重病患者未接受 RRT。其中三分之一的患者在医院死亡。死亡的时间和根本原因表明，更广泛地应用 RRT 不会改变患者的结局。
