危重症急性肾损伤成人患者肾脏替代治疗方式与长期结局的相关性：一项回顾性队列研究*。

The association between renal replacement therapy modality and long-term outcomes among critically ill adults with acute kidney injury: a retrospective cohort study*.

机构信息

1Division of Nephrology, St. Michael's Hospital and University of Toronto, Toronto, ON, Canada. 2Keenan Research Centre in the Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada. 3Institute for Clinical Evaluative Sciences, Toronto, ON, Canada. 4Department of Critical Care Medicine and Sunnybrook Research Institute, Sunnybrook Health Sciences Centre, Toronto, ON, Canada. 5Interdepartmental Division of Critical Care, University of Toronto, Toronto, ON, Canada. 6Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, AB, Canada. 7Departments of Critical Care and Medicine, St. Michael's Hospital, Toronto, ON, Canada. 8Division of Nephrology, London Health Sciences Centre, London, ON, Canada. 9Division of General Internal Medicine, St. Michael's Hospital, Toronto, ON, Canada.

出版信息

Crit Care Med. 2014 Apr;42(4):868-77. doi: 10.1097/CCM.0000000000000042.

DOI:10.1097/CCM.0000000000000042

PMID:24275513

Abstract

OBJECTIVE

Among critically ill patients with acute kidney injury, the impact of renal replacement therapy modality on long-term kidney function is unknown. Compared with conventional intermittent hemodialysis, continuous renal replacement therapy may promote kidney recovery by conferring greater hemodynamic stability; yet continuous renal replacement therapy may not enhance patient survival and is resource intense. Our objective was to determine whether continuous renal replacement therapy was associated with a lower risk of chronic dialysis as compared with intermittent hemodialysis, among survivors of acute kidney injury.

DESIGN

Retrospective cohort study.

SETTING

Linked population-wide administrative databases in Ontario, Canada.

PATIENTS

Critically ill adults who initiated dialysis for acute kidney injury between July 1996 and December 2009. In the primary analysis, we considered those who survived to at least 90 days after renal replacement therapy initiation.

INTERVENTIONS

Initial receipt of continuous renal replacement therapy versus intermittent hemodialysis.

MEASUREMENTS AND MAIN RESULTS

Continuous renal replacement therapy recipients were matched 1:1 to intermittent hemodialysis recipients based on a history of chronic kidney disease, receipt of mechanical ventilation, and a propensity score for the likelihood of receiving continuous renal replacement therapy. Cox proportional hazards were used to evaluate the relationship between initial renal replacement therapy modality and the primary outcome of chronic dialysis, defined as the need for dialysis for a consecutive period of 90 days. We identified 2,315 continuous renal replacement therapy recipients of whom 2,004 (87%) were successfully matched to 2,004 intermittent hemodialysis recipients. Participants were followed over a median duration of 3 years. The risk of chronic dialysis was significantly lower among patients who initially received continuous renal replacement therapy versus intermittent hemodialysis (hazard ratio, 0.75; 95% CI, 0.65-0.87). This relation was more prominent among those with preexisting chronic kidney disease (p value for interaction term = 0.065) and heart failure (p value for interaction term = 0.035).

CONCLUSIONS

Compared with intermittent hemodialysis, initiation of continuous renal replacement therapy in critically ill adults with acute kidney injury is associated with a lower likelihood of chronic dialysis.

摘要

目的

在急性肾损伤的危重病患者中，肾脏替代治疗方式对长期肾功能的影响尚不清楚。与常规间歇性血液透析相比，连续肾脏替代治疗通过提供更大的血流动力学稳定性可能促进肾脏恢复；然而，连续肾脏替代治疗可能不会提高患者生存率，而且资源密集度高。我们的目的是确定在急性肾损伤存活者中，与间歇性血液透析相比，连续肾脏替代治疗是否与慢性透析的风险较低相关。

设计

回顾性队列研究。

设置

加拿大安大略省的人群范围行政数据库的链接。

患者

1996 年 7 月至 2009 年 12 月期间因急性肾损伤开始透析的危重病成年人。在主要分析中，我们考虑了至少在开始肾脏替代治疗后 90 天存活的患者。

干预措施

初次接受连续肾脏替代治疗与间歇性血液透析。

测量和主要结果

根据慢性肾脏病病史、接受机械通气以及接受连续肾脏替代治疗可能性的倾向评分，对连续肾脏替代治疗接受者进行 1:1 匹配接受间歇性血液透析的接受者。使用 Cox 比例风险评估初始肾脏替代治疗方式与主要结局（定义为连续 90 天需要透析的情况）慢性透析之间的关系。我们确定了 2315 名连续肾脏替代治疗接受者，其中 2004 名（87%）成功匹配了 2004 名间歇性血液透析接受者。参与者中位随访时间为 3 年。与接受间歇性血液透析相比，最初接受连续肾脏替代治疗的患者发生慢性透析的风险显著降低（风险比，0.75；95%CI，0.65-0.87）。在有预先存在的慢性肾脏病（交互项 p 值=0.065）和心力衰竭（交互项 p 值=0.035）的患者中，这种关系更为明显。