通过在术后患者队列中联合速尿激发试验和趋化因子（C-C 基元）配体 14 预测肾脏替代治疗适应证的发展。

Predicting the Development of Renal Replacement Therapy Indications by Combining the Furosemide Stress Test and Chemokine (C-C Motif) Ligand 14 in a Cohort of Postsurgical Patients.

机构信息

Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, University Hospital Münster, Münster, Germany.

Institute of Biostatistics and Clinical Research Medical Faculty, University of Münster, Münster, Germany.

出版信息

Crit Care Med. 2023 Aug 1;51(8):1033-1042. doi: 10.1097/CCM.0000000000005849. Epub 2023 Mar 29.

DOI:10.1097/CCM.0000000000005849

PMID:36988335

原文链接:https://pmc.ncbi.nlm.nih.gov/articles/PMC10335738/

Abstract

OBJECTIVES

Optimal timing of renal replacement therapy (RRT) initiation in severe acute kidney injury (AKI) remains controversial. Initiation of treatment early in the course of AKI may lead to some patients undergoing unnecessary RRT, whereas delayed treatment is associated with increased mortality. This study aims to investigate whether the combination of the furosemide stress test (FST) and AKI-associated biomarkers can predict the development of indications for RRT.

DESIGN

Single-center, prospective, observational study.

SETTING

University Hospital of Muenster, Germany.

PATIENTS

Critically ill, postoperative patients with moderate AKI (Kidney Disease: Improving Global Outcomes stage 2) and risk factors for further progression (vasopressors and/or mechanical ventilation) receiving an FST.

INTERVENTIONS

Sample collection and measurement of different biomarkers (chemokine [C-C motif] ligand 14 [CCL14], neutrophil gelatinase-associated lipocalin, dipeptidyl peptidase 3).

MEASUREMENT AND MAIN RESULTS

The primary endpoint was the development of greater than or equal to one predefined RRT indications (hyperkalemia [≥ 6 mmol/L], diuretic-resistant hypervolemia, high urea serum levels [≥ 150 mg/dL], severe metabolic acidosis [pH ≤ 7.15], oliguria [urinary output < 200 mL/12 hr], or anuria). Two hundred eight patients were available for the primary analysis with 108 having a negative FST (urine output < 200 mL in 2 hr following FST). Ninety-eight patients (47%) met the primary endpoint, 82% in the FST negative cohort. At the time of inclusion, the combination of a negative FST test and high urinary CCL14 levels had a significantly higher predictive value for the primary endpoint with an area under the receiver operating characteristic curve (AUC) of 0.87 (95% CI, 0.82-0.92) compared with FST or CCL14 alone (AUC, 0.79; 95% CI, 0.74-0.85 and AUC, 0.83; 95% CI, 0.77-0.89; p < 0.001, respectively). Other biomarkers showed lower AUCs.

CONCLUSIONS

The combination of the FST with the renal biomarker CCL14 predicts the development of indications for RRT.

摘要

目的

在严重急性肾损伤（AKI）中，肾脏替代治疗（RRT）的最佳开始时间仍存在争议。在 AKI 病程早期开始治疗可能导致一些患者接受不必要的 RRT，而延迟治疗则与死亡率增加有关。本研究旨在探讨呋塞米应激试验（FST）和 AKI 相关生物标志物的联合应用是否可以预测 RRT 适应证的发展。

设计

单中心、前瞻性、观察性研究。

地点

德国明斯特大学医院。

患者

患有中度 AKI（肾脏病：改善全球预后阶段 2）并有进一步进展风险因素（血管加压素和/或机械通气）的术后危重症患者，接受 FST。

干预措施

采集不同生物标志物（趋化因子[C-C 基序]配体 14 [CCL14]、中性粒细胞明胶酶相关脂质运载蛋白、二肽基肽酶 3）样本并进行测量。

测量和主要结果

主要终点是出现≥1 个预先定义的 RRT 适应证（高钾血症[≥6mmol/L]、利尿剂抵抗性充血、高尿素血清水平[≥150mg/dL]、严重代谢性酸中毒[pH≤7.15]、少尿[尿量<200mL/12 小时]或无尿）。共有 208 例患者可进行主要分析，其中 108 例 FST 阴性（FST 后 2 小时内尿量<200mL）。98 例患者（47%）达到了主要终点，FST 阴性组为 82%。纳入时，FST 阴性和高尿 CCL14 水平联合检测对主要终点的预测价值显著更高，ROC 曲线下面积（AUC）为 0.87（95%CI，0.82-0.92），而单独 FST 或 CCL14 的 AUC 为 0.79（95%CI，0.74-0.85）和 AUC 为 0.83（95%CI，0.77-0.89）（p<0.001）。其他生物标志物的 AUC 较低。