Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Canada.
Interdepartmental Division of Critical Care, Department of Critical Care Medicine, Sunnybrook Health Sciences Centre.
Clin J Am Soc Nephrol. 2019 Apr 5;14(4):496-505. doi: 10.2215/CJN.05530518. Epub 2019 Mar 21.
Older patients in the intensive care unit are at greater risk of AKI; however, use of kidney replacement therapy in this population is poorly characterized. We describe the triggers and outcomes associated with kidney replacement therapy in older patients with AKI in the intensive care unit.
DESIGN, SETTING, PARTICIPANTS, & MEASUREMENTS: Our study was a prospective cohort study in 16 Canadian hospitals from September 2013 to November 2015. Patients were ≥65 years old, were critically ill, and had severe AKI; exclusion criteria were urgent kidney replacement therapy for a toxin and ESKD. We recorded triggers for kidney replacement therapy (primary exposure), reasons for not receiving kidney replacement therapy, 90-day mortality (primary outcome), and kidney recovery.
Of 499 patients, mean (SD) age was 75 (7) years old, Charlson comorbidity score was 3.0 (2.3), and median (interquartile range) Clinical Frailty Scale score was 4 (3-5). Most were receiving mechanical ventilation (64%; =319) and vasoactive support (63%; =314). Clinicians were willing to offer kidney replacement therapy to 361 (72%) patients, and 229 (46%) received kidney replacement therapy. Main triggers for kidney replacement therapy were oligoanuria, fluid overload, and acidemia, whereas main reasons for not receiving therapy were anticipated recovery (67%; =181) and therapy not consistent with patient preferences for care (24%; =66). Ninety-day mortality was similar in patients who did and did not receive kidney replacement therapy (50% versus 51%; adjusted hazard ratio, 0.78; 95% confidence interval, 0.58 to 1.06); however, decisions to offer kidney replacement therapy varied significantly by patient mix, acuity, and perceived benefit. There were no differences in health-related quality of life or rehospitalization among survivors.
Most older, critically ill patients with severe AKI were perceived as candidates for kidney replacement therapy, and approximately one half received therapy. Both willingness to offer kidney replacement therapy and reasons for not starting showed heterogeneity due to a range in patient-specific factors and clinician perceptions of benefit.
重症监护病房中的老年患者发生急性肾损伤（AKI）的风险更高；然而，该人群中肾脏替代疗法的应用情况尚不清楚。本研究旨在描述重症监护病房中 AKI 老年患者接受肾脏替代疗法的触发因素和结局。
设计、地点、参与者和测量方法：本研究为 2013 年 9 月至 2015 年 11 月在加拿大 16 家医院进行的前瞻性队列研究。纳入标准为年龄≥65 岁、病重且发生严重 AKI 的患者；排除标准为因毒素或终末期肾病而紧急接受肾脏替代治疗的患者。我们记录了肾脏替代疗法的触发因素（主要暴露因素）、未接受肾脏替代疗法的原因、90 天死亡率（主要结局）和肾脏恢复情况。
499 例患者中，平均（SD）年龄为 75（7）岁，Charlson 合并症评分 3.0（2.3）分，临床虚弱量表评分中位数（四分位距）为 4（3-5）分。大多数患者正在接受机械通气（64%，即 319 例）和血管活性药物支持（63%，即 314 例）。肾脏替代治疗的主要触发因素为少尿、液体超负荷和酸中毒，而未接受治疗的主要原因是预期恢复（67%，即 181 例）和治疗与患者对治疗的偏好不一致（24%，即 66 例）。接受和未接受肾脏替代治疗的患者 90 天死亡率相似（50%比 51%；调整后的危险比为 0.78；95%置信区间为 0.58 至 1.06）；然而，提供肾脏替代治疗的决策因患者的混杂情况、疾病严重程度和预期获益而存在显著差异。存活患者在健康相关生活质量或再住院方面无差异。
大多数重症监护病房中发生严重 AKI 的老年患者被认为是肾脏替代治疗的候选者，其中约一半患者接受了治疗。提供肾脏替代治疗的意愿和不开始治疗的原因因患者特定因素和临床医生对获益的看法的差异而存在显著异质性。
