肾脏替代治疗策略对慢性肾脏病患者结局的影响：STARRT-AKI 试验的二次分析。
Impact of renal-replacement therapy strategies on outcomes for patients with chronic kidney disease: a secondary analysis of the STARRT-AKI trial.
机构信息
Department of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta and Alberta Health Services, Edmonton, AB, Canada.
Division of Nephrology, St. Michael's Hospital, University of Toronto, Li Ka Shing Knowledge Institute of St. Michael's Hospital, Toronto, ON, Canada.
出版信息
Intensive Care Med. 2022 Dec;48(12):1736-1750. doi: 10.1007/s00134-022-06912-w. Epub 2022 Nov 4.
PURPOSE
To assess whether pre-existing chronic kidney disease (CKD) modified the relationship between the strategy for renal-replacement theraphy (RRT) initiation and clinical outcomes in the STARRT-AKI trial.
METHODS
This was a secondary analysis of a multi-national randomized trial. We included patients who had documented pre-existing estimated glomerular filtration rate (eGFR) data prior to hospitalization, and we defined CKD as an eGFR ≤ 59 mL/min/1.73 m. The primary outcome was all-cause mortality at 90 days. Secondary outcomes included RRT dependence and RRT-free days at 90 days. We used logistic and linear regression and interaction testing to explore the effect of RRT initiation strategy on outcomes by CKD status.
RESULTS
We studied 1121 patients who had pre-hospital measures of kidney function. Of these, 432 patients (38.5%) had CKD. The median (IQR) baseline serum creatinine was 130 (114-160) and 76 (64-90) µmol/L for those with and without CKD, respectively. Patients with CKD were older and more likely to have cardiovascular comorbidities and diabetes mellitus. Patients with CKD had higher 90-day mortality (47% vs. 40%, p < 0.001) compared to those without CKD, though this was not significant after covariate adjustment (adjusted odds ratio [aOR], 1.05; 95% CI, 0.79-1.41). Patients with CKD were more likely to remain RRT dependent at 90 days (14% vs. 8%; aOR, 1.89; 95% CI, 1.05-3.43). CKD status did not modify the effect of RRT initiation strategy on 90-day mortality. Among patients with CKD, allocation to the accelerated strategy conferred more than threefold greater odds of RRT dependence at 90 days (aOR 3.18; 95% CI, 1.41-7.91) compared with the standard strategy, whereas RRT initiation strategy had no effect on this outcome among those without CKD (aOR 0.71; 95% CI, 0.34-1.47, p value for interaction, 0.009).
CONCLUSION
In this secondary analysis of the STARRT-AKI trial, an accelerated strategy of RRT initiation conferred a higher risk of 90-day RRT dependence among patients with pre-existing CKD; however, no effect was observed in the absence of CKD.
目的
评估 STARRT-AKI 试验中预先存在的慢性肾脏病（CKD）是否改变了肾脏替代治疗（RRT）启动策略与临床结局之间的关系。
方法
这是一项多中心随机试验的二次分析。我们纳入了在住院前有记录的预先存在的估计肾小球滤过率（eGFR）数据的患者，并将 CKD 定义为 eGFR≤59 mL/min/1.73 m。主要结局为 90 天时的全因死亡率。次要结局包括 90 天时需要 RRT 和不需要 RRT 的天数。我们使用逻辑回归和线性回归以及交互检验来探讨 RRT 启动策略对 CKD 状态下结局的影响。
结果
我们研究了 1121 名在入院前有肾功能测量的患者。其中，432 名（38.5%）患者患有 CKD。CKD 患者的基线血清肌酐中位数（IQR）为 130（114-160），无 CKD 患者为 76（64-90）µmol/L。CKD 患者年龄较大，更可能合并心血管合并症和糖尿病。CKD 患者的 90 天死亡率较高（47% vs. 40%，p<0.001），但在调整协变量后无统计学意义（调整后的优势比[aOR]，1.05；95%CI，0.79-1.41）。CKD 患者在 90 天时更可能仍需要 RRT（14% vs. 8%；aOR，1.89；95%CI，1.05-3.43）。CKD 状态并未改变 RRT 启动策略对 90 天死亡率的影响。在 CKD 患者中，与标准策略相比，加速策略在 90 天时 RRT 依赖的可能性增加了三倍以上（aOR 3.18；95%CI，1.41-7.91），而在无 CKD 患者中，RRT 启动策略对该结局无影响（aOR 0.71；95%CI，0.34-1.47，p 值交互检验，0.009）。
结论
在 STARRT-AKI 试验的这项二次分析中，预先存在 CKD 的患者中加速 RRT 启动策略会增加 90 天 RRT 依赖的风险；然而，在不存在 CKD 的情况下，没有观察到这种效果。
Zotero 插件