Cincinnati Children's Hospital Medical Center, University of Cincinnati College of Medicine, Cincinnati, Ohio.
Seattle Children's Hospital, University of Washington, Seattle.
JAMA Netw Open. 2024 Jan 2;7(1):e2349871. doi: 10.1001/jamanetworkopen.2023.49871.
In clinical trials, the early or accelerated continuous renal replacement therapy (CRRT) initiation strategy among adults with acute kidney injury or volume overload has not demonstrated a survival benefit. Whether the timing of initiation of CRRT is associated with outcomes among children and young adults is unknown.
To determine whether timing of CRRT initiation, with and without consideration of volume overload (VO; <10% vs ≥10%), is associated with major adverse kidney events at 90 days (MAKE-90).
DESIGN, SETTING, AND PARTICIPANTS: This multinational retrospective cohort study was conducted using data from the Worldwide Exploration of Renal Replacement Outcome Collaborative in Kidney Disease (WE-ROCK) registry from 2015 to 2021. Participants included children and young adults (birth to 25 years) receiving CRRT for acute kidney injury or VO at 32 centers across 7 countries. Statistical analysis was performed from February to July 2023.
The primary exposure was time to CRRT initiation from intensive care unit admission.
The primary outcome was MAKE-90 (death, dialysis dependence, or persistent kidney dysfunction [>25% decline in estimated glomerular filtration rate from baseline]).
Data from 996 patients were entered into the registry. After exclusions (n = 27), 969 patients (440 [45.4%] female; 16 (1.9%) American Indian or Alaska Native, 40 (4.7%) Asian or Pacific Islander, 127 (14.9%) Black, 652 (76.4%) White, 18 (2.1%) more than 1 race; median [IQR] patient age, 8.8 [1.7-15.0] years) with data for the primary outcome (MAKE-90) were included. Median (IQR) time to CRRT initiation was 2 (1-6) days. MAKE-90 occurred in 630 patients (65.0%), of which 368 (58.4%) died. Among the 601 patients who survived, 262 (43.6%) had persistent kidney dysfunction. Of patients with persistent dysfunction, 91 (34.7%) were dependent on dialysis. Time to CRRT initiation was approximately 1 day longer among those with MAKE-90 (median [IQR], 3 [1-8] days vs 2 [1-4] days; P = .002). In the generalized propensity score-weighted regression, there were approximately 3% higher odds of MAKE-90 for each 1-day delay in CRRT initiation (odds ratio, 1.03 [95% CI, 1.02-1.04]).
In this cohort study of children and young adults receiving CRRT, longer time to CRRT initiation was associated with greater risk of MAKE-90 outcomes, in particular, mortality. These findings suggest that prospective multicenter studies are needed to further delineate the appropriate time to initiate CRRT and the interaction between CRRT initiation timing and VO to continue to improve survival and reduce morbidity in this population.
在临床试验中，急性肾损伤或容量超负荷的成人中早期或加速连续肾脏替代治疗 (CRRT) 的起始策略并未显示出生存获益。CRRT 起始时间是否与儿童和青年的结局相关尚不清楚。
确定 CRRT 起始时间（考虑或不考虑容量超负荷 (VO; <10% 与 ≥10%））是否与 90 天内的主要不良肾脏事件 (MAKE-90) 相关。
设计、地点和参与者：这是一项使用来自 2015 年至 2021 年期间全球肾脏替代治疗结果协作研究 (WE-ROCK) 登记处的数据进行的多中心回顾性队列研究。参与者包括在 7 个国家的 32 个中心接受 CRRT 治疗的急性肾损伤或 VO 的儿童和青年（出生至 25 岁）。统计分析于 2023 年 2 月至 7 月进行。
主要暴露是从重症监护病房入院到开始 CRRT 的时间。
主要结局是 MAKE-90（死亡、透析依赖或持续肾功能障碍 [估计肾小球滤过率从基线下降 >25%]）。
共有 996 名患者的数据被纳入登记处。排除（n=27）后，969 名患者（440 [45.4%] 女性；16 名（1.9%）美国印第安人或阿拉斯加原住民，40 名（4.7%）亚洲或太平洋岛民，127 名（14.9%）黑人，652 名（76.4%）白人，18 名（2.1%）以上 1 个种族；中位[IQR]患者年龄，8.8 [1.7-15.0] 岁）有主要结局（MAKE-90）的数据。CRRT 起始的中位（IQR）时间为 2（1-6）天。630 名患者（65.0%）发生 MAKE-90，其中 368 名（58.4%）死亡。在 601 名存活的患者中，262 名（43.6%）有持续的肾功能障碍。持续功能障碍的患者中，91 名（34.7%）依赖透析。MAKE-90 患者的 CRRT 起始时间大约延迟 1 天（中位数[IQR]，3 [1-8] 天 vs 2 [1-4] 天；P=0.002）。在广义倾向评分加权回归中，CRRT 起始每延迟 1 天，MAKE-90 的几率大约增加 3%（优势比，1.03 [95%CI，1.02-1.04]）。
在这项接受 CRRT 的儿童和青年的队列研究中，CRRT 起始时间较长与更高的 MAKE-90 结局风险相关，尤其是死亡率。这些发现表明，需要进行前瞻性多中心研究，以进一步阐明开始 CRRT 的适当时间，以及 CRRT 起始时间与 VO 之间的相互作用，以继续改善该人群的生存并降低发病率。
