Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan,
Division of Nephrology and Endocrinology, The University of Tokyo Hospital, Tokyo, Japan.
Blood Purif. 2023;52(9-10):786-792. doi: 10.1159/000532034. Epub 2023 Sep 27.
Severe acute kidney injury (AKI) requiring renal replacement therapy (RRT) has been associated with an unacceptably high mortality of 50% or more. Successful discontinuation of RRT is thought to be linked to better outcomes. Although functional and structural renal markers have been evaluated in AKI, little is known about their roles in predicting outcomes at the time of RRT discontinuation.
In this prospective single-center cohort study, we analyzed patients who received continuous RRT (CRRT) for AKI between August 2016 and March 2018 in the intensive care unit of the University of Tokyo Hospital (Tokyo, Japan). Clinical parameters and urine samples were obtained at CRRT discontinuation. Successful CRRT discontinuation was defined as neither resuming CRRT for 48 h nor receiving intermittent hemodialysis for 7 days from the CRRT termination. Major adverse kidney events (MAKEs) were defined as death, requirement for dialysis, or a decrease in the estimated glomerular filtration rate (eGFR) of more than 25% from the baseline at day 90.
Of 73 patients, who received CRRT for AKI, 59 successfully discontinued CRRT and 14 could not. Kinetic eGFR, urine volume, urinary neutrophil gelatinase-associated lipocalin (NGAL), and urinary L-type fatty acid binding protein were predictive for CRRT discontinuation. Of these factors, urine volume had the highest area under the curve (AUC) 0.91 with 95% confidence interval [0.80-0.96] for successful CRRT discontinuation. For predicting MAKEs at day 90, the urinary NGAL showed the highest AUC 0.76 [0.62-0.86], whereas kinetic eGFR and urine volume failed to show statistical significance (AUC 0.49 [0.35-0.63] and AUC 0.59 [0.44-0.73], respectively).
Our prospective study confirmed that urine volume, a functional renal marker, predicted successful discontinuation of RRT and that urinary NGAL, a structural renal marker, predicted long-term renal outcomes. These observations suggest that the functional and structural renal makers play different roles in predicting the outcomes of severe AKI requiring RRT.
需要肾脏替代治疗（RRT）的严重急性肾损伤（AKI）与 50%或更高的不可接受的高死亡率相关。人们认为成功停止 RRT 与更好的结果有关。尽管已经评估了 AKI 中的功能和结构肾标志物，但对于它们在停止 RRT 时预测结局的作用知之甚少。
在这项前瞻性单中心队列研究中，我们分析了 2016 年 8 月至 2018 年 3 月在东京大学医院（日本东京）重症监护病房接受连续 RRT（CRRT）治疗的 AKI 患者。在 CRRT 停止时获得临床参数和尿液样本。成功停止 CRRT 的定义为停止 CRRT 后 48 小时内无需再次进行 CRRT，或从 CRRT 终止后 7 天内无需间歇性血液透析。主要不良肾脏事件（MAKEs）定义为死亡、需要透析或基线后 90 天 eGFR 下降超过 25%。
在 73 例接受 AKI 行 CRRT 的患者中，59 例成功停止 CRRT，14 例不能。动力学 eGFR、尿量、尿中性粒细胞明胶酶相关脂质运载蛋白（NGAL）和尿 L 型脂肪酸结合蛋白可预测 CRRT 停止。在这些因素中，尿量的曲线下面积（AUC）最高，为 0.91（95%置信区间[0.80-0.96]），提示 CRRT 成功停止。预测 90 天 MAKEs 时，尿 NGAL 的 AUC 最高为 0.76（0.62-0.86），而动力学 eGFR 和尿量未显示统计学意义（AUC 分别为 0.49[0.35-0.63]和 0.59[0.44-0.73]）。
我们的前瞻性研究证实，尿量，一种功能肾标志物，可预测 RRT 成功停止，而尿 NGAL，一种结构肾标志物，可预测长期肾脏结局。这些观察结果表明，功能和结构肾标志物在预测需要 RRT 的严重 AKI 结局方面发挥着不同的作用。
