Department of Medicine, Division of Critical Care, McMaster University, 1200 Main St W, L8S 4L8, Hamilton, ON, Canada,
Intensive Care Med. 2015 Sep;41(9):1561-71. doi: 10.1007/s00134-015-3794-1. Epub 2015 Apr 23.
Fluid resuscitation, along with the early administration of antibiotics, is the cornerstone of treatment for patients with sepsis. However, whether differences in resuscitation fluids impact on the requirements for renal replacement therapy (RRT) remains unclear. To examine this issue, we performed a network meta-analysis (NMA), including direct and indirect comparisons, that addressed the effect of different resuscitation fluids on the use of RRT in patients with sepsis. The data sources MEDLINE, EMBASE, ACPJC, CINAHL and Cochrane Central Register were searched up to March 2014. Eligible studies included randomized trials reported in any language that enrolled adult patients with sepsis or septic shock and addressed the use of RRT associated with alternative resuscitation fluids. The risk of bias for individual studies and the overall certainty of the evidence were assessed. Ten studies (6664 patients) that included a total of nine direct comparisons were assessed. NMA at the four-node level showed that an increased risk of receiving RRT was associated with fluid resuscitation with starch versus crystalloid [odds ratio (OR) 1.39, 95% credibility interval (CrI) 1.17-1.66, high certainty]. The data suggested no difference between fluid resuscitation with albumin and crystalloid (OR 1.04, 95% CrI 0.78-1.38, moderate certainty) or starch (OR 0.74, 95% CrI 0.53-1.04, low certainty). NMA at the six-node level showed a decreased risk of receiving RRT with balanced crystalloid compared to heavy starch (OR 0.50, 95% CrI 0.34-0.74, moderate certainty) or light starch (OR 0.70, 95% CrI 0.49-0.99, high certainty). There was no significant difference between balanced crystalloid and saline (OR 0.85, 95% CrI 0.56-1.30, low certainty) or albumin (OR 0.82, 95% CrI 0.49-1.37, low certainty). Of note, these trials vary in terms of case mix, fluids evaluated, duration of fluid exposure and risk of bias. Imprecise estimates contributed to low confidence in most estimates of effect. Among the patients with sepsis, fluid resuscitation with crystalloids compared to starch resulted in reduced use of RRT; the same may be true for albumin versus starch.
液体复苏，以及早期应用抗生素，是治疗脓毒症患者的基石。然而，不同的复苏液对肾脏替代治疗（RRT）的需求是否有影响尚不清楚。为了探讨这个问题，我们进行了一项网络荟萃分析（NMA），包括直接和间接比较，以研究不同复苏液对脓毒症患者 RRT 应用的影响。数据来源为 MEDLINE、EMBASE、ACPJC、CINAHL 和 Cochrane 中央注册库，检索时间截至 2014 年 3 月。纳入的研究为任何语言报告的纳入成年脓毒症或脓毒性休克患者的随机试验，并探讨了替代复苏液与 RRT 应用相关的研究。评估了单个研究的偏倚风险和证据的总体确定性。评估了 10 项研究（6664 例患者），其中包括 9 项直接比较。在 4 节点水平的 NMA 显示，与晶体液相比，淀粉液复苏与接受 RRT 的风险增加相关[比值比（OR）1.39，95%可信区间（CrI）1.17-1.66，高确定性]。数据表明，白蛋白和晶体液（OR 1.04，95% CrI 0.78-1.38，中等确定性）或淀粉液（OR 0.74，95% CrI 0.53-1.04，低确定性）之间没有差异。在 6 节点水平的 NMA 显示，与重型淀粉液相比，平衡晶体液接受 RRT 的风险降低[比值比（OR）0.50，95% CrI 0.34-0.74，中等确定性]或轻型淀粉液（OR 0.70，95% CrI 0.49-0.99，高确定性）。平衡晶体液与生理盐水（OR 0.85，95% CrI 0.56-1.30，低确定性）或白蛋白（OR 0.82，95% CrI 0.49-1.37，低确定性）之间无显著差异。值得注意的是，这些试验在病例组合、评估的液体、液体暴露时间和偏倚风险方面存在差异。大多数效应估计的精度不高导致置信度较低。在脓毒症患者中，与淀粉液相比，晶体液复苏可减少 RRT 的应用；白蛋白与淀粉液也可能如此。
