Internal Medicine Department, Botucatu School of Medicine, University of Sao Paulo State - UNESP, Brazil.
Internal Medicine Department, Clinical Hospital of Botucatu School of Medicine, Brazil.
Perit Dial Int. 2024 Nov;44(6):445-454. doi: 10.1177/08968608231223385. Epub 2024 Jan 24.
Acute kidney injury (AKI) occurs frequently in the neurocritical intensive care unit and is associated with greater morbidity and mortality. AKI and its treatment, including acute kidney replacement therapy, can expose patients to a secondary greater brain injury. This study aimed to explore the role of peritoneal dialysis (PD) in neurocritical AKI patients in relation to metabolic and fluid control, complications related to PD and outcome.
Neurocritical AKI patients were treated by PD (prescribed Kt/V = 0.40/session) using a flexible catheter and a cycler and lactate as a buffer.
A total of 58 patients were included. The mean age was 61.8 ± 13.2 years, 65.5% were in the intensive care unit, 68.5% needed intravenous inotropic agents, 72.4% were on mechanical ventilation, APACHE II was 16 ± 6.67 and the main neurological diagnoses were stroke (25.9%) and intracerebral haemorrhage (31%). Ischaemic acute tubular necrosis (iATN) was the most common cause of AKI (51.7%), followed by nephrotoxic ATN AKI (25.8%). The main dialysis indications were uraemia and hypervolemia. Blood urea and creatinine levels stabilised after four sessions at around 48 ± 11 mg/dL and 2.9 ± 0.4 mg/dL, respectively. Negative fluid balance and ultrafiltration increased progressively and stabilised around 2.1 ± 0.4 L /day. Weekly delivered Kt/V was 2.6 ± 0.31. The median number of high-volume PD sessions was 6 (4-10). Peritonitis and mechanical complications were not frequent (8.6% and 10.3%, respectively). Mortality rate was 58.6%. Logistic regression identified as factors associated with death in neurocritical AKI patients: age (odds ratio (OR) = 1.14, 95% confidence interval (CI) = 1.09-2.16, = 0.001), nephrotoxic AKI (OR = 0.78, 95% CI = 0.69- 0.95, = 0.03), mechanical ventilation (OR = 1.54, 95% CI = 1.17-2.46, = 0.01), intracerebral haemorrhage as main neurological diagnoses (OR = 1.15, 95% CI = 1.09-2.11, = 0.03) and negative fluid balance after two PD sessions (OR = 0.94, 95% CI = 0.74-0.97, = 0.009).
Our study suggests that careful prescription may contribute to providing adequate treatment for most neurocritical AKI patients without contraindications for PD use, allowing adequate metabolic and fluid control, with no increase in the number of infectious, mechanical and metabolic complications. Mechanical ventilation, positive fluid balance and intracerebral haemorrhage were factors associated with mortality, while patients with nephrotoxic AKI had lower odds of mortality compared to those with septic and ischaemic AKI. Further studies are needed to investigate better the role of PD in neurocritical patients with AKI.
急性肾损伤（AKI）在神经重症监护病房中很常见，与更高的发病率和死亡率相关。AKI 及其治疗，包括急性肾脏替代治疗，可能会使患者遭受二次脑损伤。本研究旨在探讨腹膜透析（PD）在神经重症 AKI 患者中的作用，与代谢和液体控制、与 PD 相关的并发症和预后有关。
神经重症 AKI 患者使用灵活的导管和循环器进行 PD 治疗（规定 Kt/V = 0.40/次），并使用乳酸作为缓冲液。
共纳入 58 例患者。平均年龄为 61.8±13.2 岁，65.5%在重症监护病房，68.5%需要静脉正性肌力药物，72.4%需要机械通气，APACHE II 评分为 16±6.67，主要的神经诊断为中风（25.9%）和脑出血（31%）。缺血性急性肾小管坏死（iATN）是 AKI 最常见的原因（51.7%），其次是肾毒性 ATN AKI（25.8%）。主要的透析指征是尿毒症和血容量过多。血液尿素和肌酐水平在 48±11mg/dL 和 2.9±0.4mg/dL 左右稳定下来，分别进行了 4 次透析。负平衡和超滤逐渐增加并稳定在 2.1±0.4L/天左右。每周的 Kt/V 为 2.6±0.31。高容量 PD 次数的中位数为 6 次（4-10 次）。腹膜炎和机械并发症并不常见（分别为 8.6%和 10.3%）。死亡率为 58.6%。Logistic 回归分析确定了与神经重症 AKI 患者死亡相关的因素：年龄（比值比（OR）=1.14，95%置信区间（CI）=1.09-2.16，=0.001）、肾毒性 AKI（OR=0.78，95%CI=0.69-0.95，=0.03）、机械通气（OR=1.54，95%CI=1.17-2.46，=0.01）、脑出血为主要神经诊断（OR=1.15，95%CI=1.09-2.11，=0.03）和 PD 治疗后两次的负平衡液体（OR=0.94，95%CI=0.74-0.97，=0.009）。
我们的研究表明，谨慎的处方可能有助于为大多数没有 PD 使用禁忌的神经重症 AKI 患者提供足够的治疗，实现充分的代谢和液体控制，而不会增加感染、机械和代谢并发症的数量。机械通气、正平衡液体和脑出血是与死亡率相关的因素，而与感染性 AKI 和缺血性 AKI 相比，肾毒性 AKI 患者的死亡率较低。需要进一步的研究来更好地探讨 PD 在神经重症 AKI 患者中的作用。
