Xia Zi-Jing, He Lin-Ye, Pan Shu-Yue, Cheng Rui-Juan, Zhang Qiu-Ping, Liu Yi
Department of Rheumatology and Immunology, West China Hospital, Sichuan University, Chengdu, China.
Department of Thyroid and Parathyroid Surgery, West China Hospital, Sichuan University, Chengdu, China.
Front Med (Lausanne). 2021 Nov 18;8:580144. doi: 10.3389/fmed.2021.580144. eCollection 2021.
Timing of initiating continuous renal replacement therapies (CRRTs) among the patients with acute kidney injury (AKI) in intensive care units (ICU) has been discussed over decades, but the definition of early and late CRRT initiation is still unclear. The English language randomized controlled trials (RCTs) and cohort studies were searched through MEDLINE, EMBASE, and Cochrane Library on July 19, 2019, by the two researchers independently. The study characteristics; early and late definitions; outcomes, such as all-cause, in-hospital, 28- or 30-, 60-, 90-day mortality; and renal recovery were extracted from the 18 eligible studies. Pooled relative risk ratios (RRs) and 95% CIs were estimated with the fixed effects model and random effects model as appropriate. This study is registered with PROSPERO (CRD 42020158653). Eighteen studies including 3,914 patients showed benefit in earlier CRRT ( = 1,882) over later CRRT ( = 2,032) in all-cause mortality (RR 0.78, 95% CI 0.66-0.92), in-hospital mortality (RR 0.81, 95% CI 0.67-0.99), and 28- or 30-day mortality (RR 0.81, 95% CI 0.74-0.88), but in 60- and 90-day mortalities, no significant benefit was observed. The subgroup analysis showed significant benefit in the disease-severity-based subgroups on early CRRT initiation in terms of in-hospital mortality and 28- or 30-day mortality rather than the time-based subgroups. Moreover, early CRRT was found to have beneficial effects on renal recovery after CRRT (RR 1.21, 95% CI 1.01-1.45). Overall, compared with late CRRT, early CRRT is beneficial for short-term survival and renal recovery, especially when the timing was defined based on the disease severity. CRRT initiation on Acute Kidney Injury Network (AKIN) stage 1 or Risk, Injury, Failure, Loss of kidney function, and End-stage kidney disease (RIFLE)-Risk or less may lead to a better prognosis.
几十年来，重症监护病房（ICU）中急性肾损伤（AKI）患者开始持续肾脏替代治疗（CRRT）的时机一直备受讨论，但早期和晚期CRRT启动的定义仍不明确。2019年7月19日，两名研究人员独立通过MEDLINE、EMBASE和Cochrane图书馆检索了英文随机对照试验（RCT）和队列研究。从18项符合条件的研究中提取了研究特征、早期和晚期定义、结局指标，如全因死亡率、住院死亡率、28或30天、60天、90天死亡率以及肾脏恢复情况。根据适当情况，使用固定效应模型和随机效应模型估计合并相对风险比（RR）和95%置信区间（CI）。本研究已在PROSPERO注册（CRD 42020158653）。18项研究共纳入3914例患者，结果显示，在全因死亡率（RR 0.78，95%CI 0.66 - 0.92）、住院死亡率（RR 0.81，95%CI 0.67 - 0.99）和28或30天死亡率（RR 0.81, 95%CI 0.74 - 0.88）方面，早期CRRT（n = 1882）比晚期CRRT（n = 2032）更有益，但在60天和90天死亡率方面未观察到显著益处。亚组分析显示，基于疾病严重程度的亚组中，早期CRRT启动在住院死亡率和28或30天死亡率方面有显著益处，而非基于时间的亚组。此外，发现早期CRRT对CRRT后的肾脏恢复有有益影响（RR 1.21，95%CI 1.01 - 1.45）。总体而言，与晚期CRRT相比，早期CRRT对短期生存和肾脏恢复有益，尤其是在根据疾病严重程度定义时机时。在急性肾损伤网络（AKIN）1期或风险、损伤、衰竭、肾功能丧失和终末期肾病（RIFLE）-风险或更低水平开始CRRT可能会带来更好的预后。
