Rimes-Stigare Claire, Frumento Paolo, Bottai Matteo, Mårtensson Johan, Martling Claes-Roland, Bell Max
Section of Anaesthesia and Intensive Care Medicine, Department of Physiology and Pharmacology, Karolinska Institute, Stockholm, Sweden.
Department of Anaesthesia, Surgical Services and Intensive Care (ANOPIVA) F2, Karolinska University Hospital, Solna, 171 76, Stockholm, Sweden.
Crit Care. 2015 Nov 3;19:383. doi: 10.1186/s13054-015-1101-8.
Prevalence of chronic kidney disease (CKD) amongst intensive care unit (ICU) admissions is rising. How mortality and risk of end-stage renal disease (ESRD) differs between those with and without CKD and with acute kidney injury (AKI) is unclear. Determining factors that increase the risk of ESRD is essential to optimise treatment, identify patients requiring nephrological surveillance and for quantification of dialysis provision.
This cohort study used the Swedish intensive care register 2005-2011 consisting of 130,134 adult patients. Incomplete cases were excluded (26,771). Patients were classified (using diagnostic and intervention codes as well as admission creatinine values) into the following groups: ESRD, CKD, AKI, acute-on-chronic disease (AoC) or no renal dysfunction (control). Primary outcome was all-cause mortality. Secondary outcome was ESRD incidence.
Of 103,363 patients 4,192 had pre-existing CKD; 1389 had ESRD; 5273 developed AKI and 998 CKD patients developed AoC. One-year mortality was greatest in AoC patients (54 %) followed by AKI (48.7 %), CKD (47.6 %) and ESRD (40.3 %) (P < 0.001). Five-year mortality was highest for the CKD and AoC groups (71.3 % and 68.2 %, respectively) followed by AKI (61.8 %) and ESRD (62.9 %) (P < 0.001). ESRD incidence was greatest in the AoC and CKD groups (adjusted incidence rate ratio (IRR) 259 (95 % confidence interval (CI) 156.9-429.1) and 96.4, (95 % CI 59.7-155.6) respectively) and elevated in AKI patients compared with controls (adjusted IRR 24 (95 % CI 3.9-42.0); P < 0.001). Risk factors independently associated with ESRD in 1-year survivors were, according to relative risk ratio, AoC (356; 95 % CI 69.9-1811), CKD (267; 95 % CI 55.1-1280), AKI (30; 95 % CI 5.98-154) and presence of elevated admission serum potassium (4.6; 95 % CI 1.30-16.40) (P < 0.001).
Pre-ICU renal disease significantly increases risk of death compared with controls. Subjects with AoC disease had extreme risk of developing ESRD. All patients with CKD who survive critical care should receive a nephrology referral.
NCT02424747 April 20th 2015.
重症监护病房（ICU）收治患者中慢性肾脏病（CKD）的患病率正在上升。目前尚不清楚伴有和不伴有CKD以及伴有急性肾损伤（AKI）的患者之间，其死亡率和终末期肾病（ESRD）风险有何差异。确定增加ESRD风险的因素对于优化治疗、识别需要肾脏科监测的患者以及量化透析需求至关重要。
这项队列研究使用了2005 - 2011年瑞典重症监护登记册，其中包含130,134例成年患者。排除不完整病例（26,771例）。根据诊断和干预代码以及入院时的肌酐值，将患者分为以下几组：ESRD、CKD、AKI、慢性疾病急性发作（AoC）或无肾功能障碍（对照组）。主要结局是全因死亡率。次要结局是ESRD发病率。
在103,363例患者中，4192例患有既往CKD；1389例患有ESRD；5273例发生AKI，998例CKD患者发生AoC。1年死亡率在AoC患者中最高（54%），其次是AKI（48.7%）、CKD（47.6%）和ESRD（40.3%）（P < 0.001）。5年死亡率在CKD和AoC组中最高（分别为71.3%和68.2%），其次是AKI（61.8%）和ESRD（62.9%）（P < 0.001）。ESRD发病率在AoC和CKD组中最高（调整发病率比（IRR）分别为259（95%置信区间（CI）156.9 - 429.1）和96.4，（95% CI 59.7 - 155.6）），与对照组相比，AKI患者的发病率也有所升高（调整IRR 24（95% CI 3.9 - 42.0）；P < 0.001）。根据相对风险比，1年幸存者中与ESRD独立相关的危险因素为AoC（356；95% CI 69.9 - 1811）、CKD（267；95% CI 55.1 - 1280）、AKI（30；95% CI 5.98 - 154）以及入院时血清钾升高（4.6；95% CI 1.30 - 16.40）（P < 0.001）。
与对照组相比，入住ICU前的肾脏疾病显著增加死亡风险。患有AoC疾病的患者发生ESRD的风险极高。所有在重症监护中存活的CKD患者都应接受肾脏科转诊。
NCT02424747，2015年4月20日
