Department of Intensive Care Medicine, Austin Hospital, 145 Studley Road, Heidelberg, Melbourne, VIC, 3084, Australia.
Department of Intensive Care, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand.
Crit Care. 2022 Sep 6;26(1):269. doi: 10.1186/s13054-022-04151-5.
In critically ill patients with acute kidney injury, renal replacement therapy (RRT) modality and treatment protocols may affect kidney recovery. This study explored whether RRT modality and treatment protocol affected RRT dependence in the 'Randomized Evaluation of Normal versus Augmented Level of RRT' and the 'Acute Renal Failure Trial Network' (ATN) trials.
Primary outcome was 28-day RRT dependence. Secondary outcomes included RRT dependence among survivors and in different SOFA-based treatment protocol groups. We used the Fine-Gray competing-risk model sub-distribution hazard ratio (SHR) to assess the primary outcome. Analyses were adjusted for confounders.
Of 2542 patients, 2175 (85.5%) received continuous RRT (CRRT) and 367 (14.4%) received intermittent hemodialysis (IHD) as first RRT modality. CRRT-first patients had greater illness severity. After adjustment, there was no between-group difference in 28-day RRT dependence (SHR, 0.96 [95% CI 0.84-1.10]; p = 0.570) or hospital mortality (odds ratio [OR], 1.14 [95% CI 0.86-1.52]; p = 0.361) However, among survivors, CRRT-first was associated with decreased 28-day RRT dependence (OR, 0.54 [95% CI 0.37-0.80]; p = 0.002) and more RRT-free days (common OR: 1.38 [95% CI 1.11-1.71]). Moreover, among CRRT-first patient, the ATN treatment protocol was associated with fewer RRT-free days, greater mortality, and a fourfold increase in RRT dependence at day 28.
There was no difference in RRT dependence at day 28 between IHD and CRRT. However, among survivors and after adjustment, both IHD-first and the ATN treatment protocol were strongly associated with greater risk of RRT dependence at 28 days after randomization. Trial registration NCT00221013 registered September 22, 2005, and NCT00076219 registered January 19, 2004.
在急性肾损伤的危重症患者中，肾脏替代治疗（RRT）方式和治疗方案可能会影响肾脏的恢复。本研究旨在探讨 RRT 方式和治疗方案是否会影响“随机评估正常与增强水平的 RRT”和“急性肾损伤试验网络”（ATN）试验中的 RRT 依赖。
主要结局为 28 天的 RRT 依赖。次要结局包括幸存者和不同 SOFA 为基础的治疗方案组中的 RRT 依赖。我们使用 Fine-Gray 竞争风险模型亚分布风险比（SHR）来评估主要结局。分析调整了混杂因素。
在 2542 名患者中，2175 名（85.5%）接受了连续肾脏替代治疗（CRRT），367 名（14.4%）接受了间歇性血液透析（IHD）作为初始 RRT 方式。CRRT 组患者的疾病严重程度更高。调整后，两组间 28 天 RRT 依赖（SHR，0.96[95%CI 0.84-1.10]；p=0.570）或住院死亡率（比值比[OR]，1.14[95%CI 0.86-1.52]；p=0.361）均无差异。然而，在幸存者中，CRRT 作为初始治疗与 28 天 RRT 依赖降低（OR，0.54[95%CI 0.37-0.80]；p=0.002）和更多的无 RRT 天数（常见 OR：1.38[95%CI 1.11-1.71]）相关。此外，在 CRRT 组患者中，ATN 治疗方案与无 RRT 天数减少、死亡率增加以及第 28 天 RRT 依赖增加四倍有关。
在第 28 天，IHD 和 CRRT 之间的 RRT 依赖没有差异。然而，在幸存者中，并且在调整后，IHD 作为初始治疗和 ATN 治疗方案均与随机分组后第 28 天 RRT 依赖的风险显著增加相关。
NCT00221013 于 2005 年 9 月 22 日注册，NCT00076219 于 2004 年 1 月 19 日注册。
