de Souza Oliveira Marisa Aparecida, Dos Santos Thais Oliveira Claizoni, Monte Julio Cesar Martins, Batista Marcelo Costa, Pereira Virgilio Gonçalves, Dos Santos Bento Fortunato Cardoso, Santos Oscar Fernando Pavão, de Souza Durão Marcelino
Nephrology Division of Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627, Morumbi, São Paulo, 05652-900, Brazil.
Nephrology Division of Universidade Federal de São Paulo, Rua Botucatu, 740, Vila Clementino, São Paulo, 04023-062, Brazil.
BMC Nephrol. 2017 May 3;18(1):150. doi: 10.1186/s12882-017-0564-z.
Many controversies exist regarding the management of dialysis-requiring acute kidney injury (D-AKI). No clear evidence has shown that the choice of dialysis modality can change the survival rate or kidney function recovery of critically ill patients with D-AKI.
We conducted a retrospective study investigating patients (≥16 years old) admitted to an intensive care unit with D-AKI from 1999 to 2012. We analyzed D-AKI incidence, and outcomes, as well as the most commonly used dialysis modality over time. Outcomes were based on hospital mortality, renal function recovery (estimated glomerular filtration rate-eGFR), and the need for dialysis treatment at hospital discharge.
In 1,493 patients with D-AKI, sepsis was the main cause of kidney injury (56.2%). The comparison between the three study periods, (1999-2003, 2004-2008, and 2009-2012) showed an increased in incidence of D-AKI (from 2.56 to 5.17%; p = 0.001), in the APACHE II score (from 20 to 26; p < 0.001), and in the use of continuous renal replacement therapy (CRRT) as initial dialysis modality choice (from 64.2 to 72.2%; p < 0.001). The mortality rate (53.9%) and dialysis dependence at hospital discharge (12.3%) remained unchanged over time. Individuals who recovered renal function (33.8%) showed that those who had initially undergone CRRT had a higher eGFR than those in the intermittent hemodialysis group (54.0 × 46.0 ml/min/1.73 m2, respectively; p = 0.014). In multivariate analysis, type of patient, sepsis-associated AKI and APACHE II score were associated to death. For each additional unit of the APACHE II score, the odds of death increased by 52%. The odds ratio of death for medical patients with sepsis-associated AKI was estimated to be 2.93 (1.81-4.75; p < 0.001).
Our study showed that the incidence of D-AKI increased with illness severity, and the use of CRRT also increased over time. The improvement in renal outcomes observed in the CRRT group may be related to the better baseline kidney function, especially in the dialysis dependence patients at hospital discharge.
对于需要透析的急性肾损伤（D-AKI）的管理存在许多争议。尚无明确证据表明透析方式的选择能够改变D-AKI危重症患者的生存率或肾功能恢复情况。
我们进行了一项回顾性研究，调查了1999年至2012年入住重症监护病房的D-AKI患者（≥16岁）。我们分析了D-AKI的发病率、结局以及随时间推移最常用的透析方式。结局基于医院死亡率、肾功能恢复情况（估算肾小球滤过率-eGFR）以及出院时是否需要透析治疗。
在1493例D-AKI患者中，脓毒症是肾损伤的主要原因（56.2%）。三个研究时间段（1999 - 2003年、2004 - 2008年和2009 - 2012年）的比较显示，D-AKI发病率增加（从2.56%增至5.17%；p = 0.001），急性生理与慢性健康状况评分系统II（APACHE II）评分增加（从20增至26；p < 0.001），以及作为初始透析方式选择的连续性肾脏替代治疗（CRRT）的使用增加（从64.2%增至72.2%；p < 0.001）。死亡率（53.9%）和出院时的透析依赖情况（12.3%）随时间保持不变。肾功能恢复的个体（33.8%）显示，最初接受CRRT的患者的eGFR高于间歇性血液透析组的患者（分别为54.0×46.0 ml/min/1.73m²；p = 0.014）。在多变量分析中，患者类型、脓毒症相关急性肾损伤和APACHE II评分与死亡相关。APACHE II评分每增加一个单位，死亡几率增加52%。脓毒症相关急性肾损伤的内科患者的死亡比值比估计为2.93（1.81 - 4.75；p < 0.001）。
我们的研究表明，D-AKI的发病率随疾病严重程度增加，并且CRRT的使用也随时间增加。CRRT组观察到的肾功能结局改善可能与更好的基线肾功能有关，尤其是在出院时依赖透析的患者中。
