Rodenas-Alesina Eduard, Wang Vicki N, Brahmbhatt Darshan H, Scolari Fernando Luis, Mihajlovic Vesna, Fung Nicole L, Otsuki Madison, Billia Filio, Overgaard Christopher B, Luk Adriana
Division of Cardiology, Department of Medicine, Peter Munk Cardiac Centre, University Health Network, University of Toronto, 585 University Avenue, 4N 478, Toronto, ON M5G 2N2, Canada.
Ted Rogers Centre for Heart Research, 661 University Avenue, Toronto, ON M5G 1X8, Canada.
Eur Heart J Acute Cardiovasc Care. 2022 Jun 14;11(5):377-385. doi: 10.1093/ehjacc/zuac024.
The clinical predictors and outcomes of patients with cardiogenic shock (CS) requiring renal replacement therapy (RRT) have not been studied previously. This study assesses the impact of RRT on mortality in patients with CS and aims to identify clinical factors that contribute to the need of RRT.
Consecutive patients presenting with CS were included from a prospective registry of cardiac intensive care unit admissions at a single institution between 2014 and 2020. Of the 1030 patients admitted with CS, 123 (11.9%) received RRT. RRT was associated with higher 1-year mortality [adjusted hazard ratio = 1.62, 95% confidence interval (CI) 1.02-2.14], and a higher in-hospital incidence of sepsis [risk ratio = 2.76, P < 0.001], and pneumonia (risk ratio = 2.9, P = 0.001). Those who received RRT were less likely to receive guideline-directed medical treatment at time of discharge, undergo heart transplantation (2.4% vs. 11.5%, P = 0.002) or receive a durable left ventricular assist device (0.0% vs. 11.6%, P < 0.001). Five variables at admission best predicted the need for RRT (age, lactate, haemoglobin, use of pre-admission loop diuretics, and admission estimated glomerular filtration rate) and were used to generate the CALL-K 9-point risk score, with better discrimination than creatinine alone (P = 0.008). The score was internally validated (area under the curve = 0.815, 95% CI 0.739-0.835) with good calibration (Hosmer-Lemeshow P = 0.827).
RRT is associated with worse outcomes, including a lower likelihood to receive advanced heart failure therapies in patients with CS. A risk score comprising five variables routinely collected at admission can accurately estimate the risk of needing RRT.
既往尚未对需要肾脏替代治疗（RRT）的心源性休克（CS）患者的临床预测因素及预后进行研究。本研究评估RRT对CS患者死亡率的影响，并旨在确定导致需要RRT的临床因素。
连续纳入2014年至2020年期间在单一机构的心脏重症监护病房前瞻性登记处登记的CS患者。在1030例因CS入院的患者中，123例（11.9%）接受了RRT。RRT与1年更高的死亡率相关[调整后风险比=1.62，95%置信区间（CI）1.02 - 2.14]，以及更高的院内脓毒症发病率[风险比=2.76，P<0.001]和肺炎发病率（风险比=2.9，P = 0.001）。接受RRT的患者在出院时接受指南指导的药物治疗、接受心脏移植（2.4%对11.5%，P = 0.002）或接受持久性左心室辅助装置的可能性较小（0.0%对11.6%，P<0.001）。入院时的五个变量最能预测RRT的需求（年龄、乳酸、血红蛋白、入院前袢利尿剂的使用以及入院时估计的肾小球滤过率），并用于生成CALL-K 9分风险评分，其辨别能力优于单独的肌酐（P = 0.008）。该评分经内部验证（曲线下面积=0.815，95%CI 0.739 - 0.835），校准良好（Hosmer-Lemeshow P = 0.827）。
RRT与更差的预后相关，包括CS患者接受晚期心力衰竭治疗的可能性更低。一个包含入院时常规收集的五个变量的风险评分可以准确估计需要RRT的风险。
