Pan Heng-Chih, Huang Tao-Min, Sun Chiao-Yin, Chou Nai-Kuan, Tsao Chun-Hao, Yeh Fang-Yu, Lai Tai-Shuan, Chen Yung-Ming, Wu Vin-Cent
Graduate Institute of Clinical Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan.
Chang Gung University College of Medicine, Taoyuan, Taiwan.
EClinicalMedicine. 2022 Jan 10;44:101232. doi: 10.1016/j.eclinm.2021.101232. eCollection 2022 Feb.
Renal replacement therapy (RRT) is an effective rescue therapy for Type 1 cardiorenal syndrome (CRS). Previous studies have demonstrated that type 1 CRS patients with severe renal dysfunction were susceptible to sepsis, and that serum lactate has been correlated with the risk of mortality in patients with sepsis. However, the association between serum lactate level and the prognosis of type 1 CRS patients requiring RRT is unknown.
An inception cohort of 500 type 1 CRS patients who received RRT in a tertiary-care referral hospital in Taiwan from August 2011 to January 2018 were enrolled. The outcomes of interest were dialysis withdrawal and 90-day mortality. The results were further externally validated using sampling data of type 1 CRS patients requiring dialysis from multiple tertiary-care centers.
The 90-day mortality rate was 52.8% and the incidence rate of dialysis withdrawal was 34.8%. Lower pre-dialysis lactate was correlated with a higher rate of dialysis withdrawal and lower rate of mortality. Generalized additive model showed that 4.2 mmol/L was an adequate cut-off value of lactate to predict mortality. Taking mortality as a competing risk, Fine-Gray subdistribution hazard analysis further indicated that a low lactate level (≦ 4.2 mmol/L) was an independent predictor for the possibility of dialysis withdrawal, as also shown in external validation. The interaction of quick Sequential Organ Failure Assessment score and lactate was associated with dialysis dependence in a disease severity-dependent manner. Furthermore, the associations between hyperlactatemia and dialysis dependence were consistent in the patients with and without sepsis.
Serum lactate level is accurate and capable of forecasting the prognosis along with qSOFA severity for clinical decision-making for treating type 1 CRS patients. Further studies are needed to validate our results.
This study was supported by grants from Taiwan National Science Council [104-2314-B-002-125-MY3,106-2314-B-002-166-MY3,107-2314-B-002-026-MY3], National Taiwan University Hospital [106-FTN20,106-P02,UN106-014,106-S3582,107-S3809,107-T02,PC1246,VN109-09,109-S4634,UN109-041], Ministry of Science and Technology of the Republic of China [MOST106-2321-B-182-002,106-2314-B-182A-064,MOST107-2321-B-182-004,MOST107-2314-B-182A-138, MOST108-2321-B-182-003,MOST109-2321-B-182-001, MOST108-2314-B-182A-027], Chang Gung Memorial Hospital [CMRPG-2G0361,CMRPG-2H0161,CMRPG-2J0261, CMRPG-2K0091], and Ministry of Health and Welfare of the Republic of China [PMRPG-2L0011].
肾脏替代疗法（RRT）是治疗1型心肾综合征（CRS）的一种有效挽救疗法。既往研究表明，严重肾功能不全的1型CRS患者易发生脓毒症，且血清乳酸水平与脓毒症患者的死亡风险相关。然而，血清乳酸水平与需要接受RRT的1型CRS患者预后之间的关联尚不清楚。
纳入2011年8月至2018年1月在台湾一家三级转诊医院接受RRT的500例1型CRS患者的起始队列。感兴趣的结局为透析撤机和90天死亡率。使用来自多个三级医疗中心的1型CRS透析患者的抽样数据对结果进行外部验证。
90天死亡率为52.8%，透析撤机发生率为34.8%。透析前较低的乳酸水平与较高的透析撤机率和较低的死亡率相关。广义相加模型显示，4.2 mmol/L是预测死亡率的乳酸合适临界值。将死亡率作为竞争风险，Fine-Gray子分布风险分析进一步表明，低乳酸水平（≤4.2 mmol/L）是透析撤机可能性的独立预测因素，外部验证也显示了这一点。快速序贯器官衰竭评估评分与乳酸的相互作用以疾病严重程度依赖的方式与透析依赖相关。此外，高乳酸血症与透析依赖之间的关联在脓毒症患者和非脓毒症患者中是一致的。
血清乳酸水平准确且能够与qSOFA严重程度一起预测预后，可为治疗1型CRS患者的临床决策提供依据。需要进一步研究来验证我们的结果。
本研究得到了台湾国家科学委员会[104 - 2314 - B - 002 - 125 - MY3,106 - 2314 - B - 002 - 166 - MY3,107 - 2314 - B - 002 - 026 - MY3]、台湾大学医院[106 - FTN20,106 - P02,UN106 - 014,106 - S3582,107 - S3809,107 - T02,PC1246,VN109 - 09,109 - S4634,UN109 - 041]、中华民国科学技术部[MOST(106 - 2321 - B - 182 - 002,106 - 2314 - B - 182A - 064,MOST107 - 2321 - B - 182 - 004,MOST107 - 2314 - B - 182A - 138, MOST108 - 2321 - B - 182 - 003,MOST109 - 2321 - B - 182 - 001, MOST108 - 2314 - B - 182A - 027)]、长庚纪念医院[CMRPG - 2G0361,CMRPG - 2H0161,CMRPG - 2J0261, CMRPG - 2K0091]以及中华民国卫生福利部[PMRPG - 2L0011]的资助。
