Ponce Daniela, Zamoner Welder, Addad Vanessa, Batistoco Marci Maria, Balbi André
Internal Department, University State of Sao Paulo- UNESP, Botucatu, Sao Paulo, Brazil.
Clinical Hospital of Botucatu Medical School, Botucatu, Sao Paulo, Brazil.
Int J Nephrol Renovasc Dis. 2020 Sep 4;13:203-209. doi: 10.2147/IJNRD.S251127. eCollection 2020.
Acute renal replacement therapy (RRT) is indicated when metabolic and fluid demands exceed total kidney capacity, and demand for kidney function is determined by non-renal comorbidities, severity of acute disease and solute and fluid burden; therefore, the criteria for commencing RRT and dialysis in intensive care units (ICUs) may be different to those outside ICUs.
We investigated whether criteria for commencing acute RRT and dialysis outside ICU were different to those in ICU and whether these differences affected patient mortality in either setting.
We performed a retrospective observational study evaluating acute kidney injury (AKI), Kidney Disease Improving Global Outcome 3 (KDIGO3) in adult patients undergoing RRT "in and outside" ICU from 2012 to 2018, in a Brazilian teaching hospital.
We evaluated 913 adults with AKI KDIGO3 undergoing RRT; 629 (68.9%) outside ICU and 284 (31.1%) in ICU. Infections were the main cause of hospitalisation (34.4%). Septic and ischaemic AKI were the main aetiologies of AKI (50.8% and 32.9%, respectively), metabolic and fluid demand to capacity imbalance were the main indications for dialysis (69.7%), and intermittent haemodialysis (IHD) was the primary dialysis method (59.2%). The general mortality rate after 30 days was 59%. There were no differences in gender, age and main diagnosis between groups. Both groups were different in acute tubular necrosis index specific scores (ATN-ISS), AKI aetiology, elderly population, indications for dialysis, dialysis methods and mortality rates. In ICU, patients older than 65 years old, with septic AKI were more prevalent (49.1 versus 41.4%, and 55.1 versus 37.5%, respectively), while ischaemic and nephrotoxic AKI were less frequent (24.3 versus 37 and 10.2 versus 16.3%, respectively), and ATN-ISS was higher (0.74 ± 0.31 versus 0.58 ± 0.16). Similarly, metabolic and fluid demand to capacity imbalance as an indication for acute RRT, prolonged intermittent haemodialysis (PIRRT) and continuous renal replacement therapy (CRRT) were more frequent, while peritoneal dialysis (PD) was less frequent (74.6 versus 69.7%, 31.6 versus 22.4%, and 5.3 versus 17.8%, respectively), and mortality was higher (69 versus 54.7%, respectively). Logistic regression revealed that age, septic AKI and being "in" ICU were factors associated with death.
The criteria for commencing RRT and dialysis in ICU were different to those outside ICU; however, they did not impact on patient outcomes.
当代谢和液体需求超过肾脏总能力时，需进行急性肾脏替代治疗（RRT），而对肾功能的需求由非肾脏合并症、急性疾病的严重程度以及溶质和液体负荷决定；因此，重症监护病房（ICU）开始RRT和透析的标准可能与ICU以外的情况不同。
我们调查了ICU以外开始急性RRT和透析的标准是否与ICU内不同，以及这些差异是否影响两种情况下患者的死亡率。
我们进行了一项回顾性观察研究，评估了2012年至2018年在巴西一家教学医院接受“ICU内外”RRT的成年患者的急性肾损伤（AKI）、改善全球肾脏病预后组织3（KDIGO3）情况。
我们评估了913例接受RRT的AKI KDIGO3成年患者；629例（68.9%）在ICU以外，284例（31.1%）在ICU内。感染是住院的主要原因（34.4%）。脓毒症性和缺血性AKI是AKI的主要病因（分别为50.8%和32.9%），代谢和液体需求与能力失衡是透析的主要指征（69.7%），间歇性血液透析（IHD）是主要的透析方法（59.2%）。30天后的总体死亡率为59%。两组在性别、年龄和主要诊断方面无差异。两组在急性肾小管坏死指数特定评分（ATN-ISS）、AKI病因、老年人群、透析指征、透析方法和死亡率方面均不同。在ICU中，65岁以上、患有脓毒症性AKI的患者更为普遍（分别为49.1%对41.4%，55.1%对37.5%），而缺血性和肾毒性AKI则较少见（分别为24.3%对37%，10.2%对16.3%），且ATN-ISS更高（0.74±0.31对0.58±0.16）。同样，作为急性RRT指征的代谢和液体需求与能力失衡、延长间歇性血液透析（PIRRT）和连续性肾脏替代治疗（CRRT）更为常见，而腹膜透析（PD）则较少见（分别为74.6%对69.7%，31.6%对22.4%，5.3%对17.8%），死亡率更高（分别为69%对54.7%）。逻辑回归显示，年龄、脓毒症性AKI和在“ICU内治疗”是与死亡相关的因素。
ICU内开始RRT和透析的标准与ICU以外不同；然而，它们并未影响患者的预后。
