Department of Critical Care Medicine, The Center for Critical Care Nephrology, CRISMA, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
Department of Critical Care Medicine, The Clinical Research, Investigation, and Systems Modeling of Acute Illness (CRISMA) Center, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
Crit Care. 2018 Sep 24;22(1):223. doi: 10.1186/s13054-018-2163-1.
Although net ultrafiltration (UF) is frequently used for treatment of fluid overload in critically ill patients with acute kidney injury, the optimal intensity of UF is unclear. Among critically ill patients with fluid overload receiving renal replacement therapy (RRT), we examined the association between UF intensity and risk-adjusted 1-year mortality.
We selected patients with fluid overload ≥ 5% of body weight prior to initiation of RRT from a large academic medical center ICU dataset. UF intensity was calculated as the net volume of fluid ultrafiltered per day from initiation of either continuous or intermittent RRT until the end of ICU stay adjusted for patient hospital admission body weight. We stratified UF as low (≤ 20 ml/kg/day), moderate (> 20 to ≤ 25 ml/kg/day) or high (> 25 ml/kg/day) intensity. We adjusted for age, sex, body mass index, race, surgery, baseline estimated glomerular filtration rate, oliguria, first RRT modality, pre-RRT fluid balance, duration of RRT, time to RRT initiation from ICU admission, APACHE III score, mechanical ventilation use, suspected sepsis, mean arterial pressure on day 1 of RRT, cumulative fluid balance during RRT and cumulative vasopressor dose during RRT. We fitted logistic regression for 1-year mortality, Gray's survival model and propensity matching to account for indication bias.
Of 1075 patients, the distribution of high, moderate and low-intensity UF groups was 40.4%, 15.2% and 44.2% and 1-year mortality was 59.4% vs 60.2% vs 69.7%, respectively (p = 0.003). Using logistic regression, high-intensity compared with low-intensity UF was associated with lower mortality (adjusted odds ratio 0.61, 95% CI 0.41-0.93, p = 0.02). Using Gray's model, high UF was associated with decreased mortality up to 39 days after ICU admission (adjusted hazard ratio range 0.50-0.73). After combining low and moderate-intensity UF groups (n = 258) and propensity matching with the high-intensity group (n = 258), UF intensity > 25 ml/kg/day compared with ≤ 25 ml/kg/day was associated with lower mortality (57% vs 67.8%, p = 0.01). Findings were robust to several sensitivity analyses.
Among critically ill patients with ≥ 5% fluid overload and receiving RRT, UF intensity > 25 ml/kg/day compared with ≤ 20 ml/kg/day was associated with lower 1-year risk-adjusted mortality. Whether tolerating intensive UF is just a marker for recovery or a mediator requires further research.
尽管净超滤（UF）经常用于治疗伴有急性肾损伤的危重症患者的液体超负荷，但 UF 的最佳强度尚不清楚。在接受肾脏替代治疗（RRT）的伴有液体超负荷的危重症患者中，我们研究了 UF 强度与风险调整后 1 年死亡率之间的关系。
我们从一家大型学术医疗中心 ICU 数据集的患者中选择了在开始 RRT 之前存在液体超负荷≥5%体重的患者。UF 强度被计算为从开始连续或间歇性 RRT 到 ICU 住院期间结束时每天净超滤的液体量，根据患者入院时的体重进行调整。我们将 UF 分为低（≤20 ml/kg/天）、中（>20 至≤25 ml/kg/天）或高（>25 ml/kg/天）强度。我们调整了年龄、性别、体重指数、种族、手术、基线估算肾小球滤过率、少尿、第一 RRT 方式、预 RRT 液体平衡、RRT 持续时间、从 ICU 入院到开始 RRT 的时间、急性生理学和慢性健康评估 III 评分、机械通气使用、疑似败血症、RRT 第 1 天的平均动脉压、RRT 期间的累积液体平衡和 RRT 期间的累积血管加压药剂量。我们使用逻辑回归进行 1 年死亡率、灰色生存模型和倾向匹配来纠正适应证偏差。
在 1075 名患者中，高、中、低强度 UF 组的分布分别为 40.4%、15.2%和 44.2%，1 年死亡率分别为 59.4%、60.2%和 69.7%（p=0.003）。使用逻辑回归，高强度 UF 与低强度 UF 相比，死亡率较低（调整后的优势比 0.61，95%CI 0.41-0.93，p=0.02）。使用灰色模型，UF 高与 ICU 入院后 39 天内死亡率降低有关（调整后的危险比范围 0.50-0.73）。在将低强度和中强度 UF 组（n=258）合并，并与高强度组（n=258）进行倾向匹配后，UF 强度>25 ml/kg/天与≤25 ml/kg/天相比，死亡率较低（57% vs 67.8%，p=0.01）。研究结果在多项敏感性分析中是稳健的。
在伴有≥5%液体超负荷且接受 RRT 的危重症患者中，与≤20 ml/kg/天相比，UF 强度>25 ml/kg/天与较低的 1 年风险调整死亡率相关。是否耐受强化 UF 只是恢复的标志还是中介，还需要进一步研究。
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