Müller R B, Haase N, Lange T, Wetterslev J, Perner A
Department of Intensive Care, Rigshospitalet, University of Copenhagen, Copenhagen, Denmark.
Acta Anaesthesiol Scand. 2015 Mar;59(3):329-36. doi: 10.1111/aas.12453. Epub 2014 Dec 18.
We aimed to detail the effects of hydroxyethyl starch (HES) vs. Ringer's on kidney function including the interaction with mortality in post-hoc analyses as resuscitation with HES 130/0.42 increased mortality in the Scandinavian Starch for Severe Sepsis/Septic Shock (6S) trial.
In all 798 randomised patients, we assessed the incidence and effect on mortality of acute kidney injury (AKI) in the HES vs. Ringer's acetate groups using the Kidney Disease: Improving Global Outcome criteria. We also assessed the intervention effect on time to and duration of renal replacement therapy (RRT).
At baseline, the intervention groups were similar. The maximal AKI stage was higher in the HES vs. Ringer's group within the first 5 days after randomisation (P = 0.03), the average difference being 0.2 points (P < 0.01). An increase in AKI stage was associated with mortality (hazard ratio (HR) 1.35; 95% CI 1.22 to 1.49; P < 0.01). Significantly, more patients in the HES group received RRT within the first 5 days (P = 0.01), and the time to initiation of RRT was also shorter compared with the Ringer's group (HR 1.40; 95% CI 1.01-1.93; P = 0.04). The intervention effect of HES on mortality was reduced when adjusting for AKI stage as a time-dependent covariate (P = 0.15).
In patients with severe sepsis, HES appeared to increase the rate of severe AKI and use of RRT within the first 5 days. The increased mortality observed with HES may have been partly mediated through acute kidney impairment.
我们旨在详细阐述羟乙基淀粉（HES）与林格氏液对肾功能的影响，包括在事后分析中与死亡率的相互作用，因为在斯堪的纳维亚严重脓毒症/脓毒性休克淀粉研究（6S）试验中，使用130/0.42的HES进行复苏会增加死亡率。
在所有798例随机分组的患者中，我们使用改善全球肾脏病预后组织的标准，评估了HES组与醋酸林格氏液组急性肾损伤（AKI）的发生率及其对死亡率的影响。我们还评估了干预措施对开始肾脏替代治疗（RRT）的时间及RRT持续时间的影响。
在基线时，各干预组情况相似。随机分组后的前5天内，HES组的最大AKI分期高于林格氏液组（P = 0.03），平均差异为0.2分（P < 0.01）。AKI分期增加与死亡率相关（风险比[HR] 1.35；95%置信区间1.22至1.49；P < 0.01）。值得注意的是，HES组中更多患者在头5天内接受了RRT（P = 0.01），与林格氏液组相比，开始RRT的时间也更短（HR 1.40；95%置信区间1.01 - 1.93；P = 0.04）。将AKI分期作为时间依赖性协变量进行校正后，HES对死亡率的干预效果降低（P = 0.15）。
在严重脓毒症患者中，HES似乎在头5天内增加了严重AKI的发生率及RRT的使用。观察到的HES导致死亡率增加可能部分是通过急性肾损伤介导的。
