重症监护中的急性肾损伤：保守治疗策略的经验

Acute kidney injury in critical care: experience of a conservative strategy.

作者信息

Gaudry Stéphane, Ricard Jean-Damien, Leclaire Clément, Rafat Cédric, Messika Jonathan, Bedet Alexandre, Regard Lucile, Hajage David, Dreyfuss Didier

机构信息

AP-HP, Hôpital Louis Mourier, Service de Réanimation Médico-Chirurgicale, 178 rue des Renouillers, F-92700, Colombes, France; Univ Paris Diderot, Sorbonne Paris Cité, ECEVE, UMRS 1123, F-75010 Paris, France; INSERM, ECEVE, U1123, F-75010 Paris, France.

AP-HP, Hôpital Louis Mourier, Service de Réanimation Médico-Chirurgicale, 178 rue des Renouillers, F-92700, Colombes, France; Univ Paris Diderot, Sorbonne Paris Cité, IAME, UMRS 1137, F-75018 Paris, France; INSERM, IAME, U1137, F-75018 Paris, France.

出版信息

J Crit Care. 2014 Dec;29(6):1022-7. doi: 10.1016/j.jcrc.2014.07.014. Epub 2014 Jul 22.

DOI:10.1016/j.jcrc.2014.07.014

PMID:25123792

Abstract

PURPOSE

Renal replacement therapy (RRT) is a major supportive treatment of acute kidney injury (AKI) in intensive care unit (ICU), but the timing of its initiation remains open to debate.

MATERIALS AND METHODS

We retrospectively analyzed ICU patients who had AKI associated with at least one usual RRT criteria: serum creatinine concentration greater than 300 μmol/L, serum urea concentration greater than 25 mmol/L, serum potassium concentration greater than 6.5 mmol/L, severe metabolic acidosis (arterial blood pH<7.2), oliguria (urine output<135 mL/8 hours or <400 mL/24 hours), overload pulmonary edema. To estimate the risk of death associated with RRT adjusted for risk factors, we performed a marginal structural Cox model with inverse-probability-of-treatment-weighted estimator.

RESULTS

Among 4173 patients admitted to the ICU, 203 patients fulfilled potential RRT criteria. Ninety-one patients (44.8%) received RRT and 112 (55.2%) did not. Non-RRT and RRT patients differed in terms of severity of illness: Simplified Acute Physiology Score II (55±17 vs 60±19, respectively; P<.05) and Sequential Organ Failure Assessment score (8 [5-10] vs 9 [7-11], respectively; P=.01). Crude analysis indicated a lower ICU mortality for non-RRT compared with RRT patients (18% vs 45%; P<.001). In the marginal structural Cox model, RRT was associated with increased mortality (P<.01).

CONCLUSION

A conservative approach of AKI was not associated with increased mortality.

摘要

目的

肾脏替代治疗（RRT）是重症监护病房（ICU）中急性肾损伤（AKI）的主要支持治疗方法，但其开始时机仍存在争议。

材料与方法

我们回顾性分析了符合至少一项常规RRT标准的AKI的ICU患者：血清肌酐浓度大于300μmol/L、血清尿素浓度大于25mmol/L、血清钾浓度大于6.5mmol/L、严重代谢性酸中毒（动脉血pH<7.2）、少尿（尿量<135mL/8小时或<400mL/24小时）、容量负荷性肺水肿。为了评估经风险因素调整后的与RRT相关的死亡风险，我们使用治疗权重逆概率估计器进行了边际结构Cox模型分析。

结果

在4173例入住ICU的患者中，203例符合潜在RRT标准。91例患者（44.8%）接受了RRT，112例（55.2%）未接受。未接受RRT和接受RRT的患者在疾病严重程度方面存在差异：简化急性生理学评分II分别为（55±17对60±19；P<0.05）和序贯器官衰竭评估评分分别为（8[5 - 10]对9[7 - 11]；P = 0.01）。粗分析表明，与接受RRT的患者相比，未接受RRT的患者ICU死亡率较低（18%对45%；P<0.001）。在边际结构Cox模型中，RRT与死亡率增加相关（P<0.01）。