Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
Acta Anaesthesiol Scand. 2021 Sep;65(8):1079-1086. doi: 10.1111/aas.13841. Epub 2021 May 24.
Acute kidney injury (AKI) is often diagnosed based on plasma creatinine (Cr) only. Adjustment of Cr for cumulative fluid balance due to potential dilution of Cr and subsequently missed Cr-based diagnosis of AKI has been suggested, albeit the physiological rationale for these adjustments is questionable. Furthermore, whether these adjustments lead to a different incidence of AKI when used in conjunction with urine output (UO) criteria is unknown.
This was a post hoc analysis of the Finnish Acute Kidney Injury study. Hourly UO and daily plasma Cr were measured during the first 5 days of intensive care unit admission. Cr values were adjusted following the previously used formula and combined with the UO criteria. Resulting incidences and mortality rates were compared with the results based on unadjusted values.
In total, 2044 critically ill patients were analyzed. The mean difference between the adjusted and unadjusted Cr of all 7279 observations was 5 (±15) µmol/L. Using adjusted Cr in combination with UO and renal replacement therapy criteria resulted in the diagnosis of 19 (1%) additional AKI patients. The absolute difference in the incidence was 0.9% (95% confidence interval [CI]: 0.3%-1.6%). Mortality rates were not significantly different between the reclassified AKI patients using the full set of Kidney Disease: Improving Global Outcomes criteria.
Fluid balance-adjusted Cr resulted in little change in AKI incidence, and only minor differences in mortality between patients who changed category after adjustment and those who did not. Using adjusted Cr values to diagnose AKI does not seem worthwhile in critically ill patients.
急性肾损伤（AKI）通常仅基于血浆肌酐（Cr）进行诊断。已经提出了由于 Cr 的潜在稀释而对 Cr 进行累积液体平衡调整，以避免漏诊 AKI，但这些调整的生理原理是有问题的。此外，当与尿量（UO）标准一起使用时，这些调整是否会导致 AKI 的发生率不同尚不清楚。
这是芬兰急性肾损伤研究的事后分析。在重症监护病房入院的前 5 天内，每小时测量 UO 和每日血浆 Cr。根据先前使用的公式调整 Cr 值，并将其与 UO 标准相结合。将得出的发生率和死亡率与基于未调整值的结果进行比较。
总共分析了 2044 名危重症患者。所有 7279 次观察的调整后和未调整后 Cr 值之间的平均差异为 5（±15）µmol/L。使用调整后的 Cr 值与 UO 和肾脏替代治疗标准相结合，诊断出 19 名（1%）额外的 AKI 患者。发生率的绝对差异为 0.9%（95%置信区间 [CI]：0.3%-1.6%）。在使用肾脏病：改善全球结局（KDIGO）全套标准重新分类的 AKI 患者中，死亡率没有显著差异。
液体平衡调整后的 Cr 值对 AKI 发生率的变化很小，并且对调整后类别发生变化的患者和未发生变化的患者的死亡率只有微小差异。在危重症患者中，使用调整后的 Cr 值诊断 AKI 似乎没有价值。
