肾脏替代治疗强度与急性肾损伤恢复至透析独立性的关系：系统评价和个体患者数据分析荟萃分析。

Renal replacement therapy intensity for acute kidney injury and recovery to dialysis independence: a systematic review and individual patient data meta-analysis.

机构信息

Renal and Metabolic Division, George Institute for Global Health, Camperdown, NSW, Australia.

Concord Clinical School, Sydney Medical School, University of Sydney, Sydney, NSW, Australia.

出版信息

Nephrol Dial Transplant. 2018 Jun 1;33(6):1017-1024. doi: 10.1093/ndt/gfx308.

DOI:10.1093/ndt/gfx308

PMID:29186517

Abstract

BACKGROUND

There is no consensus whether higher intensity dose renal replacement therapy (RRT) compared with standard intensity RRT has survival benefit and achieves better renal recovery in acute kidney injury (AKI).

METHODS

In an individual patient data meta-analysis, we merged individual patient data from randomized controlled trials (RCTs) comparing high with standard intensity RRT in intensive care unit patients with severe AKI. The primary outcome was all-cause mortality. The secondary outcome was renal recovery assessed as the proportion of patients who were RRT dependent at key trial endpoints and by time to the end of RRT dependence.

RESULTS

Of the eight prospective RCTs assessing different RRT intensities, seven contributed individual patient data (n = 3682) to the analysis. Mortality was similar between the two groups at 28 days [769/1884 (40.8%) and 744/1798 (41.4%), respectively; P = 0.40] after randomization. However, more participants assigned to higher intensity therapy remained RRT dependent at the most common key study point of 28 days [e.g. 292/983 (29.7%) versus 235/943 (24.9%); relative risk 1.15 (95% confidence interval 1.00-1.33); P = 0.05]. Time to cessation of RRT through 28 days was longer in patients receiving higher intensity RRT (log-rank test P = 0.02) and when continuous renal replacement therapy was used as the initial modality of RRT (log-rank test P = 0.03).

CONCLUSIONS

In severe AKI patients, higher intensity RRT does not affect mortality but appears to delay renal recovery.

TRIAL REGISTRATION

Australian New Zealand Clinical Trials Registry (ANZCTR) identifier ACTRN12615000394549 (https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?ACTRN=12615000394549).

摘要

背景

目前尚不确定与标准强度肾脏替代疗法（RRT）相比，更高强度剂量的 RRT 是否具有生存获益，并能在急性肾损伤（AKI）中实现更好的肾脏恢复。

方法

在一项个体患者数据的荟萃分析中，我们合并了来自随机对照试验（RCT）的个体患者数据，这些 RCT 比较了重症 AKI 患者接受高强度与标准强度 RRT 的效果。主要结局是全因死亡率。次要结局是肾脏恢复情况，评估指标为关键试验终点时以及结束 RRT 依赖时需要 RRT 的患者比例。

结果

在评估不同 RRT 强度的八项前瞻性 RCT 中，有七项向分析提供了个体患者数据（n=3682）。随机分组后 28 天时两组死亡率相似[分别为 769/1884（40.8%）和 744/1798（41.4%）；P=0.40]。然而，更多接受高强度治疗的患者在最常见的 28 天关键研究点仍需接受 RRT[例如，983 例患者中有 292 例（29.7%），943 例患者中有 235 例（24.9%）；相对风险 1.15（95%置信区间 1.00-1.33）；P=0.05]。接受高强度 RRT 的患者停止 RRT 的时间（通过 28 天时间的对数秩检验 P=0.02）和初始 RRT 采用连续肾脏替代疗法的患者（对数秩检验 P=0.03）的时间更长。