评估连续性肾脏替代治疗期间规定的与实现的液体平衡与死亡率结局。
Assessment of prescribed vs. achieved fluid balance during continuous renal replacement therapy and mortality outcome.
机构信息
Division of Nephrology, Department of Internal Medicine, Bone and Mineral Metabolism, University of Kentucky, Lexington, Kentucky, United States of America.
Division of Nephrology, Department of Internal Medicine, University of Alabama at Birmingham, Birmingham, Alabama, United States of America.
出版信息
PLoS One. 2022 Aug 25;17(8):e0272913. doi: 10.1371/journal.pone.0272913. eCollection 2022.
BACKGROUND
Fluid management during continuous renal replacement therapy (CRRT) requires accuracy in the prescription of desired patient fluid balance (FBGoal) and precision in the attainable patient fluid balance (FBAchieved). Herein, we examined the association of the gap between prescribed vs. achieved patient fluid balance during CRRT (%FBGap) with hospital mortality in critically ill patients.
METHODS
Cohort study of critically ill adults with acute kidney injury (AKI) requiring CRRT and a prescription of negative fluid balance (mean patient fluid balance goal of negative ≥0.5 liters per day). Fluid management parameters included: 1) NUF (net ultrafiltration rate); 2) FBGoal; 3) FBAchieved; and 4) FBGap (% gap of fluid balance achieved vs. goal), all adjusted by patient's weight (kg) and duration of CRRT (hours).
RESULTS
Data from 653 patients (median of 102.2 patient-hours of CRRT) were analyzed. Mean (SD) age was 56.7 (14.6) years and 61.9% were male. Hospital mortality rate was 64%. Despite FBGoal was similar in patients who died vs. survived, survivors achieved greater negative fluid balance during CRRT than non-survivors: median FBAchieved -0.25 [-0.52 to -0.05] vs. 0.06 [-0.26 to 0.62] ml/kg/h, p<0.001. Median NUF was lower in patients who died vs. survived: 1.06 [0.63-1.47] vs. 1.22 [0.82-1.69] ml/kg/h, p<0.001, and median %FBGap was higher in patients who died (112.8%, 61.5 to 165.7) vs. survived (64.2%, 30.5 to 91.8), p<0.001. In multivariable models, higher %FBGap was independently associated with increased risk of hospital mortality: aOR (95% CI) 1.01 (1.01-1.02), p<0.001. NUF was not associated with hospital mortality when adjusted by %FBGap and other clinical parameters: aOR 0.96 (0.72-1.28), p = 0.771.
CONCLUSIONS
Higher %FBGap was independently associated with an increased risk of hospital mortality in critically ill adults with AKI on CRRT in whom clinicians prescribed negative fluid balance via CRRT. %FBGap represents a novel quality indicator of CRRT delivery that could assist with operationalizing fluid management interventions during CRRT.
背景
连续性肾脏替代治疗（CRRT）期间的液体管理需要准确地规定所需的患者液体平衡（FBGoal）和精确地实现患者液体平衡（FBAchieved）。在此，我们研究了 CRRT 期间规定的与实现的患者液体平衡之间的差距（%FBGap）与危重症患者住院死亡率之间的关联。
方法
这是一项对需要 CRRT 且处方为负液体平衡（平均患者液体平衡目标为每天负≥0.5 升）的急性肾损伤（AKI）的危重症成年患者的队列研究。液体管理参数包括：1）净超滤率（NUF）；2）FBGoal；3）FBAchieved；4）%FBGap（实现的液体平衡与目标之间的差距），均根据患者的体重（kg）和 CRRT 的持续时间（小时）进行调整。
结果
对 653 例患者（CRRT 中位数为 102.2 个患者小时）的数据进行了分析。平均（SD）年龄为 56.7（14.6）岁，61.9%为男性。住院死亡率为 64%。尽管死亡患者与存活患者的 FBGoal 相似，但存活患者在 CRRT 期间实现了更大的负液体平衡：中位数 FBAchieved -0.25[-0.52 至-0.05]与 0.06[-0.26 至 0.62]ml/kg/h，p<0.001。死亡患者的 NUF 中位数低于存活患者：1.06[0.63-1.47]与 1.22[0.82-1.69]ml/kg/h，p<0.001，死亡患者的中位数%FBGap 更高（112.8%，61.5%至 165.7%）与存活患者（64.2%，30.5%至 91.8%）相比，p<0.001。在多变量模型中，较高的%FBGap 与住院死亡率增加独立相关：比值比（95%CI）1.01（1.01-1.02），p<0.001。当通过%FBGap 和其他临床参数调整时，NUF 与住院死亡率无关：比值比 0.96（0.72-1.28），p=0.771。
结论
在接受 CRRT 的 AKI 危重症成人中，较高的%FBGap 与通过 CRRT 规定负液体平衡的临床医生的住院死亡率增加独立相关。%FBGap 是 CRRT 实施的一种新的质量指标，可协助在 CRRT 期间实施液体管理干预措施。
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