Anesthesiology and Intensive Care Unit, University of Health Sciences, Bakırköy Sadi Konuk Training and Research Hospital, Istanbul, Turkey.
University of Healthy Sciences, Bakırkoy Dr. Sadi Konuk Training and Research Hospital, Istanbul, Turkey.
Ther Apher Dial. 2020 Aug;24(4):445-452. doi: 10.1111/1744-9987.13449. Epub 2019 Nov 29.
The aim of our study is to evaluate the impact of early vs. late initiation of continuous renal replacement therapy (CRRT), defined by clinical information system (CIS) software using an early warning algorithm based on acute kidney injury network (AKIN) stages, on survival outcome of critically ill intensive care unit (ICU) patients with acute kidney injury (AKI). Of 1144 patients (mean [SD] age: 61.3 [17.9] years, 57.7% were males) hospitalized in ICU over a 2-year-period from January 2016 to December 2017, a total of 272 patients who had developed AKI requiring CRRT were included in this retrospective cross-sectional study. Data on patient demographics (age, gender), reason for ICU hospitalization, AKIN stage, Sequential Organ Failure Assessment (SOFA) score, Acute Physiology and Chronic Health Evaluation II (APACHE II) score, indications for CRRT, and time of CRRT initiation with respect to AKIN early warning algorithm were retrieved from hospital records and the CIS software database. Survivorship status was assessed based on total, in-hospital and 90-day post-discharge mortality rates and analyzed with respect to CRRT onset before vs. after AKIN alarm. CRRT was initiated before the AKIN alarm in 41(15.0%) patients, and after the AKIN alarm in 231(85.0%) patients involving treatment within 0-24 h of alarm in 146 (63.2%) patients and within 24-120 h of alarm in 85 (36.8%) patients. Mortality occurred in 175 (64.3%) patients involving 25 (61.0%) out of 41 patients who received CRRT before AKIN alarm and 150 (64.9%) out of 231 patients who received CRRT after AKIN alarm. Mortality rate was significantly higher in those who received CRRT 24-120 h vs. 0-24 h after the AKIN alarm (82.4% vs. 54.8%, P < 0.001). Pre- and post-CRRT SOFA scores were significantly lower in patients who received CRRT 0-24 h vs. 24-120 h after the AKIN alarm (P = 0.009 and P = 0.004, respectively), while pre-CRRT APACHE II scores were significantly lower in patients who received CRRT before vs. after the AKIN alarm (P = 0.008). In conclusion, our findings indicate the potential role of using AKIN stage-based early warning system in guiding time to start CRRT and improved survival in critically ill patients with AKI, provided that the CRRT was initiated within the early (first 24 h) of the alarming AKIN Stage II-III events. Future well-designed clinical trials addressing early vs. late initiation of CRRT in critical care patients with AKI are needed to find and answer to the ongoing controversy and help clinicians in refining their indications for starting CRRT.
我们的研究目的是评估基于急性肾损伤网络（AKIN）分期的临床信息系统（CIS）软件早期预警算法定义的早期与晚期开始连续性肾脏替代治疗（CRRT）对伴有急性肾损伤（AKI）的重症监护病房（ICU）危重症患者生存结局的影响。在 2016 年 1 月至 2017 年 12 月的 2 年期间，ICU 共收治了 1144 例患者（平均[SD]年龄：61.3[17.9]岁，57.7%为男性），其中共有 272 例因 AKI 需要接受 CRRT 的患者被纳入本回顾性横断面研究。从医院记录和 CIS 软件数据库中提取了患者人口统计学特征（年龄、性别）、入住 ICU 的原因、AKIN 分期、序贯器官衰竭评估（SOFA）评分、急性生理学和慢性健康评估 II（APACHE II）评分、CRRT 适应证以及相对于 AKIN 早期预警算法的 CRRT 开始时间等数据。根据总死亡率、住院内死亡率和出院后 90 天死亡率评估生存状态，并分析 CRRT 起始时间与 AKIN 报警之间的关系。在 41 例（15.0%）患者中 CRRT 起始于 AKIN 报警之前，在 231 例（85.0%）患者中 CRRT 起始于 AKIN 报警之后，其中 146 例（63.2%）患者在 AKIN 报警后 0-24 小时内开始治疗，85 例（36.8%）患者在 AKIN 报警后 24-120 小时内开始治疗。在 175 例（64.3%）死亡患者中，有 25 例（61.0%）患者在 AKIN 报警前接受了 CRRT，有 150 例（64.9%）患者在 AKIN 报警后接受了 CRRT。AKIN 报警后 24-120 小时接受 CRRT 的死亡率明显高于 0-24 小时（82.4% vs. 54.8%，P<0.001）。在 AKIN 报警后 0-24 小时接受 CRRT 的患者的 CRRT 前后 SOFA 评分明显低于 AKIN 报警后 24-120 小时接受 CRRT 的患者（P=0.009 和 P=0.004），而在 AKIN 报警前接受 CRRT 的患者的 CRRT 前 APACHE II 评分明显低于 AKIN 报警后接受 CRRT 的患者（P=0.008）。总之，我们的研究结果表明，使用基于 AKIN 分期的早期预警系统来指导 CRRT 开始时间可能有助于改善伴有 AKI 的危重症患者的生存，前提是 CRRT 在报警的 AKIN Ⅱ-Ⅲ期事件发生后的早期（前 24 小时）开始。需要进行未来的精心设计的临床试验，以确定并回答关于 CRRT 在伴有 AKI 的重症监护患者中的早期与晚期开始的争议，并帮助临床医生完善 CRRT 的适应证。
