Schoenfelder Tonio, Chen Xiaoyu, Bleß Hans-Holger
IGES Institut GmbH, Berlin, Germany.
GMS Health Technol Assess. 2017 Mar 1;13:Doc01. doi: 10.3205/hta000127. eCollection 2017.
Dialysis-dependent acute kidney injury (AKI) can be treated using continuous (CRRT) or intermittent renal replacement therapies (IRRT). Although some studies suggest that CRRT may have advantages over IRRT, study findings are inconsistent. This study assessed differences between CRRT and IRRT regarding important clinical outcomes (such as mortality and renal recovery) and cost-effectiveness. Additionally, ethical aspects that are linked to renal replacement therapies in the intensive care setting are considered. Systematic searches in MEDLINE, EMBASE, and Cochrane Library including RCTs, observational studies, and cost-effectiveness studies were performed. Results were pooled using a random effects-model. Forty-nine studies were included. Findings show a higher rate of renal recovery among survivors who initially received CRRT as compared with IRRT. This advantage applies to the analysis of all studies with different observation periods (Relative Risk (RR) 1.10; 95% Confidence Interval (CI) [1.05, 1.16]) and to a selection of studies with observation periods of 90 days (RR 1.07; 95% CI [1.04, 1.09]). Regarding observation periods beyond there are no differences when only two identified studies were analyzed. Patients initially receiving CRRT have higher mortality as compared to IRRT (RR 1.17; 95% CI [1.06, 1.28]). This difference is attributable to observational studies and may have been caused by allocation bias since seriously ill patients more often initially receive CRRT instead of IRRT. CRRT do not significantly differ from IRRT with respect to change of mean arterial pressure, hypotensive episodes, hemodynamic instability, and length of stay. Data on cost-effectiveness is inconsistent. Recent analyzes indicate that initial CRRT is cost-effective compared to initial IRRT due to a reduction of the rate of long-term dialysis dependence. As regards a short time horizon, this cost benefit has not been shown. Findings of the conducted assessment show that initial CRRT is associated with higher rates of renal recovery. Potential long-term effects on clinical outcomes for more than three months could not be analyzed and should be investigated in further studies. Economical analyzes indicate that initial CRRT is cost-effective when costs of long-term dialysis dependence are considered. However, transferability of the economic analyzes to the German health care system is limited and the conduction of economical analyzes using national cost data should be considered.
依赖透析的急性肾损伤（AKI）可采用连续性（CRRT）或间歇性肾脏替代疗法（IRRT）进行治疗。尽管一些研究表明CRRT可能比IRRT更具优势，但研究结果并不一致。本研究评估了CRRT和IRRT在重要临床结局（如死亡率和肾功能恢复）及成本效益方面的差异。此外，还考虑了重症监护环境中与肾脏替代疗法相关的伦理问题。对MEDLINE、EMBASE和Cochrane图书馆进行了系统检索，纳入随机对照试验、观察性研究和成本效益研究。结果采用随机效应模型进行汇总。共纳入49项研究。结果显示，与接受IRRT的幸存者相比，最初接受CRRT的幸存者肾功能恢复率更高。这一优势适用于对所有不同观察期研究的分析（相对风险（RR）1.10；95%置信区间（CI）[1.05, 1.16]）以及对观察期为90天的部分研究的分析（RR 1.07；95%CI [1.04, 1.09]）。对于超过该观察期的情况，在仅分析两项已确定研究时未发现差异。与接受IRRT的患者相比，最初接受CRRT的患者死亡率更高（RR 1.17；95%CI [1.06, 1.28]）。这一差异归因于观察性研究，可能是由于分配偏倚导致的，因为重症患者更常最初接受CRRT而非IRRT。在平均动脉压变化、低血压发作、血流动力学不稳定和住院时间方面，CRRT与IRRT无显著差异。成本效益数据不一致。近期分析表明，由于长期透析依赖率降低，初始CRRT与初始IRRT相比具有成本效益。但在短期范围内，尚未显示出这种成本效益。所进行评估的结果表明，初始CRRT与更高的肾功能恢复率相关。无法分析对三个月以上临床结局的潜在长期影响，应在进一步研究中进行调查。经济分析表明，考虑长期透析依赖成本时，初始CRRT具有成本效益。然而，经济分析对德国医疗保健系统的可转移性有限，应考虑使用国家成本数据进行经济分析。
