Division of Nephrology, Department of Pediatrics & Communicable Diseases, C.S. Mott Children's Hospital, University of Michigan, Ann Arbor, MI, USA.
Crit Care Med. 2012 Sep;40(9):2694-9. doi: 10.1097/CCM.0b013e318258ff01.
In pediatric patients, fluid overload at continuous renal replacement therapy initiation is associated with increased mortality. The aim of this study was to characterize the association between fluid overload at continuous renal replacement therapy initiation, fluid removal during continuous renal replacement therapy, the kinetics of fluid removal and mortality in a large pediatric population receiving continuous renal replacement therapy while on extracorporeal membrane oxygenation.
Retrospective chart review.
Tertiary children's hospital.
Extracorporeal membrane oxygenation patients requiring continuous renal replacement therapy from July 2006 to September 2010.
None.
Overall intensive care unit survival was 34% for 53 patients that were initiated on continuous renal replacement therapy while on extracorporeal membrane oxygenation during the study period. Median fluid overload at continuous renal replacement therapy initiation was significantly lower in survivors compared to nonsurvivors (24.5% vs. 38%, p = .006). Median fluid overload at continuous renal replacement therapy discontinuation was significantly lower in survivors compared to nonsurvivors (7.1% vs. 17.5%, p = .035). After adjusting for percent fluid overload at continuous renal replacement therapy initiation, age, and severity of illness, the change in fluid overload at continuous renal replacement therapy discontinuation was not significantly associated with mortality (p = .212). Models investigating the rates of fluid removal in different periods, age, severity of illness, and fluid overload at continuous renal replacement therapy initiation found that fluid overload at continuous renal replacement therapy initiation was the most consistent predictor of survival.
Our data demonstrate an association between fluid overload at continuous renal replacement therapy initiation and mortality in pediatric patients receiving extracorporeal membrane oxygenation. The degree of fluid overload at continuous renal replacement therapy discontinuation is also associated with mortality, but appears to reflect the effect of fluid overload at initiation. Furthermore, correction of fluid overload to ≤ 10% was not associated with improved survival. These results suggest that intervening prior to the development of significant fluid overload may be more clinically effective than attempting fluid removal after significant fluid overload has developed. Our findings suggest a role for earlier initiation of continuous renal replacement therapy in this population, and warrant further clinical studies.
在接受连续性肾脏替代治疗（CRRT）的儿科患者中，起始时的液体超负荷与死亡率增加有关。本研究的目的是描述在接受体外膜肺氧合（ECMO）的大量儿科患者中，CRRT 起始时的液体超负荷、CRRT 期间的液体清除量、液体清除动力学与死亡率之间的关联。
回顾性图表审查。
三级儿童医院。
2006 年 7 月至 2010 年 9 月期间需要 ECMO 支持的接受 CRRT 的患者。
无。
在研究期间，53 名接受 ECMO 支持的患者开始接受 CRRT，总体 ICU 生存率为 34%。与幸存者相比，非幸存者的 CRRT 起始时的液体超负荷中位数明显更高（24.5%对 38%，p=0.006）。与非幸存者相比，幸存者的 CRRT 停止时的液体超负荷中位数明显更低（7.1%对 17.5%，p=0.035）。在校正 CRRT 起始时的液体超负荷百分比、年龄和疾病严重程度后，CRRT 停止时液体超负荷的变化与死亡率无显著相关性（p=0.212）。在调查不同时间段、年龄、疾病严重程度和 CRRT 起始时液体超负荷的液体清除率的模型中，发现 CRRT 起始时的液体超负荷是生存的最一致预测因素。
我们的数据表明，在接受 ECMO 的儿科患者中，CRRT 起始时的液体超负荷与死亡率相关。CRRT 停止时的液体超负荷程度也与死亡率相关，但似乎反映了起始时液体超负荷的影响。此外，将液体超负荷纠正至≤10%并未提高生存率。这些结果表明，在发生明显液体超负荷之前进行干预可能比在发生明显液体超负荷后进行液体清除更为有效。我们的发现表明，在该人群中更早开始 CRRT 可能具有作用，并需要进一步的临床研究。
