Department of Anesthesiology and Critical Care, The University of Pennsylvania Perelman School of Medicine and Children's Hospital of Philadelphia, Philadelphia, PA, USA.
Pediatr Nephrol. 2024 Jul;39(7):2217-2226. doi: 10.1007/s00467-024-06320-w. Epub 2024 Feb 23.
Acute kidney injury (AKI) is a common complication of critical illness and associated with high morbidity and mortality. Optimal timing of continuous kidney replacement therapy (CKRT) in children is unknown. We aimed to measure the association between timing of initiation and mortality.
This is a single-center retrospective cohort study of pediatric patients receiving CKRT from 2013 to 2019. The primary exposure, time to CKRT initiation, was measured from onset of stage 3 AKI during hospitalization (defined using Kidney Disease: Improving Global Outcomes creatinine and urine output criteria) and analyzed as both a continuous and categorical variable. The primary outcome was ICU mortality.
Ninety-nine patients met criteria for analysis. Overall mortality was 39% (39/99). Median time from stage 3 AKI onset to CKRT initiation was 1.5 days in survivors and 5.5 days in nonsurvivors (p < 0.001). In multivariable analysis, increased time to CKRT initiation was independently associated with mortality [OR 1.02 per hour (95% CI 1.01-1.04), p < 0.001]. Longer time to CKRT initiation was associated with higher odds of mortality in ascending time intervals. Patients started on CKRT > 2 days compared to < 2 days after stage 3 AKI onset had higher mortality (65% vs. 5%, p < 0.001), longer median ICU length of stay (25 vs. 12 d, p < 0.001), longer median CKRT duration (11 vs. 5 d, p < 0.001), and fewer AKI-free days (0 vs. 14 d, p < 0.001).
Longer time to initiation of CKRT after development of severe AKI is independently associated with mortality. Consideration of early CKRT in this high-risk population may be a strategy to reduce mortality and improve recovery of kidney function. However, there remains significant heterogeneity in the definition of early versus late initiation and the optimal timing of CKRT remains unknown.
急性肾损伤（AKI）是危重病的常见并发症，与高发病率和死亡率相关。儿童连续性肾脏替代治疗（CKRT）的最佳时机尚不清楚。我们旨在测量开始时间与死亡率之间的关联。
这是一项对 2013 年至 2019 年期间接受 CKRT 的儿科患者进行的单中心回顾性队列研究。主要暴露因素，即 CKRT 开始时间，是从住院期间 3 期 AKI 的发作开始测量的（使用肾脏病：改善全球预后肌酐和尿输出标准定义），并作为连续和分类变量进行分析。主要结局是 ICU 死亡率。
99 名患者符合分析标准。总体死亡率为 39%（39/99）。存活者从 3 期 AKI 发作到 CKRT 开始的中位时间为 1.5 天，而死亡者为 5.5 天（p<0.001）。在多变量分析中，CKRT 开始时间的增加与死亡率独立相关[每小时 1.02 的比值比（95%可信区间 1.01-1.04），p<0.001]。随着时间间隔的延长，CKRT 开始时间的延长与死亡率的升高呈正相关。与 3 期 AKI 发作后 2 天内开始 CKRT 相比，>2 天开始 CKRT 的患者死亡率更高（65%比 5%，p<0.001），ICU 住院时间中位数更长（25 比 12 d，p<0.001），CKRT 持续时间中位数更长（11 比 5 d，p<0.001），AKI 无天数更少（0 比 14 d，p<0.001）。
在严重 AKI 发生后开始 CKRT 的时间延长与死亡率独立相关。在这个高危人群中考虑早期 CKRT 可能是降低死亡率和改善肾功能恢复的策略。然而，早期与晚期开始的定义以及 CKRT 的最佳时机仍然存在显著的异质性。
