Vinclair Camille, De Montmollin Etienne, Sonneville Romain, Reuter Jean, Lebut Jordane, Cally Radj, Mourvillier Bruno, Neuville Mathilde, Ruckly Stéphane, Timsit Jean-François, Bouadma Lila
Medical and Infectious Intensive Care Unit, Bichat Claude Bernard University Hospital, AP-HP, 46 rue Henri Huchard, 75018, Paris, France.
UMR 1137-IAME Team 5-DeSCID: Decision SCiences in Infectious Diseases control and care INSERM/Univ Paris Diderot, Sorbonne Paris Cité, 75018, Paris, France.
Ann Intensive Care. 2020 Apr 20;10(1):44. doi: 10.1186/s13613-020-00656-w.
To describe acute kidney injury (AKI) natural history and to identify predictors of major adverse kidney events (MAKE) within 1 year in patients supported by veno-arterial extracorporeal membrane oxygenation (VA-ECMO).
Retrospective observational study.
Medical French intensive care unit between January 2014 and December 2016.
Consecutive patients implanted with VA-ECMO ≥ 16 years, VA-ECMO for at least ≥ 48 h, and without end-stage chronic kidney disease (CKD).
None.
Multivariate logistic regression of factors associated with MAKE at 1 year defined as one of the following criteria within day 360: death and receipt of renal replacement therapy (RRT) or persistent renal dysfunction, i.e., CKD ≥ stage 3 corresponding to an estimated glomerular filtration rate (eGFR) ≤ 60 ml/min/1.73 m and MAKE at day 30 and day 90 defined as one of the following criteria within day 30 or day 90: death, receipt of renal replacement therapy and serum creatinine ≥ threefold increase.
158 consecutive patients were included (male sex: 75.9%; median and interquartile range: age: 59 [47-66], Simplified Acute Physiology Score II: 55 [39-66], Sepsis-related Organ Failure Assessment Score: 9 [7-12], time on VA-ECMO: 7.5 [4-12] days). Among them 145 (91.8%) developed an AKI during the intensive care unit (ICU) stay and 85 (53.8%) needed renal replacement therapy (RRT). 59.9% (91/152), 60.5% (89/147) and 85.1% (120/141) evaluable patients had a MAKE-30, MAKE-90 and MAKE-360, respectively. Factors significantly associated with MAKE-360 were eGFR at baseline (odds ratio (OR) 0.98, confidence interval 95% (CI) [0.97;1.00], p 0.02), Kidney Disease Improving Global Outcome (KDIGO) stage at cannulation (p = 0.03), e.g., stage 3 vs. reference stage 0 OR 10.20 [1.77-58.87], and number of red blood cell (RBC) packs received while under ECMO (OR 1.14, CI 95% [1.01;1.28], p = 0.03). At 1 year among the 51 survivors, almost half of the alive patients (n = 20/51) had a decline of estimated glomerular filtration (eGFR) > 30% mL/min/1.73 m. Their median eGFR decline was - 26.3% [- 46.6;- 10.7].
Patients undergoing VA-ECMO had a high risk of AKI during the ICU stay. Factors associated with MAKE 360 were mainly eGFR at baseline, KDIGO stage at cannulation and, number of RBC packs received while under ECMO. Among survivors at 1 year, almost half of the alive patients (n = 20/51) had a decline eGFR > 30%.
描述急性肾损伤（AKI）的自然病程，并确定接受静脉-动脉体外膜肺氧合（VA-ECMO）支持的患者在1年内发生主要不良肾脏事件（MAKE）的预测因素。
回顾性观察研究。
2014年1月至2016年12月期间法国的一家医疗重症监护病房。
连续纳入年龄≥16岁、接受VA-ECMO至少≥48小时且无终末期慢性肾脏病（CKD）的患者。
无。
对与1年内MAKE相关的因素进行多因素逻辑回归分析，MAKE定义为360天内符合以下标准之一：死亡、接受肾脏替代治疗（RRT）或持续性肾功能不全，即CKD≥3期，对应估计肾小球滤过率（eGFR）≤60 ml/min/1.73 m²；30天和90天时的MAKE定义为30天或90天内符合以下标准之一：死亡、接受肾脏替代治疗和血清肌酐升高≥3倍。
共纳入158例连续患者（男性占75.9%；年龄中位数及四分位间距：59岁[47-66岁]，简化急性生理学评分II：55分[39-66分]，脓毒症相关器官功能衰竭评估评分：9分[7-12分]，VA-ECMO支持时间：7.5天[4-12天]）。其中145例（91.8%）在重症监护病房（ICU）住院期间发生AKI，85例（53.8%）需要接受肾脏替代治疗（RRT）。在可评估的患者中，59.9%（91/152）、60.5%（89/147）和85.1%（120/141）分别在30天、90天和360天时发生MAKE。与360天时MAKE显著相关的因素包括基线eGFR（比值比（OR）0.98，95%置信区间（CI）[0.97；1.00]，p = 0.02）、插管时的改善全球肾脏病预后组织（KDIGO）分期（p = 0.03），例如3期与参照0期相比，OR为10.20 [1.77-58.87]，以及在ECMO支持期间接受的红细胞（RBC）血袋数量（OR 1.14，95%CI [1.01；1.28]，p = 0.03）。在1年时，51例幸存者中，近一半存活患者（n = 20/51）的估计肾小球滤过率（eGFR）下降>30% mL/min/1.73 m²。其eGFR下降的中位数为-26.3% [-46.6；-10.7]。
接受VA-ECMO的患者在ICU住院期间发生AKI的风险较高。与360天时MAKE相关的因素主要包括基线eGFR、插管时的KDIGO分期以及在ECMO支持期间接受的RBC血袋数量。在1年时的幸存者中，近一半存活患者（n = 20/51）的eGFR下降>30%。
