Jiang R, Shen Y N, Liu K, Xu W, Xing C Y, Mao H J, Wu B Y
Department of Nephrology, the First Affiliated Hospital of Nanjing Medical University (Jiangsu Province Hospital), Nanjing210029, China.
Zhonghua Yi Xue Za Zhi. 2024 Nov 26;104(44):4073-4080. doi: 10.3760/cma.j.cn112137-20240407-00808.
To evaluate the association between fluid balance within 48 hours after initiating continuous renal replacement therapy (CRRT) and 90-day mortality of patients with cardiac surgery-associated acute kidney injury (CSA-AKI). Adult patients who received CRRT for CSA-AKI for more than 24 hours between January 2016 and December 2021 in the First Affiliated Hospital of Nanjing Medical University were prospectively included. Exposures were fluid input, fluid output, fluid balance and percentage of fluid overload change (defined as weight-standardized fluid input/output difference) within 48 hours after CRRT initiation. The primary outcome was 90-day mortality. The relationship between the exposures and 90-day mortality was determined by restricted cubic spline and segmented Cox regression. The study enrolled 262 patients, and 90-day mortality was 60.3% (158/262). There were 171 males and 91 females, with a median age of 64 (54, 71) years. The dead patients (=158) had more fluid input [6.43 (5.62, 7.34) L vs 6.07 (5.09, 6.90) L, 0.013], greater fluid balance [-0.01 (-1.36, 1.34) L vs -0.65 (-1.71, 0.42) L, =0.005] and higher percentage of fluid overload change [-0.01% (-2.17%, 2.01%) vs -0.85% (-2.49%, 0.52%), 0.013] within 48 hours after CRRT initiation than the survived patients (=104). The cumulative fluid balance and fluid overload changes have a "J" curve relationship with 90-day mortality. Higher positive fluid balance (adjusted per 1 L increase above 0.5 L=1.33, 95%: 1.17-1.50) and greater proportion of fluid overload changes (adjusted per 1% increase above 0.7%=1.20, 90%: 1.11-1.30) were associated with an increased risk of death. Cumulative fluid input was linearly related to the 90-day mortality. Higher input (adjusted per 1 L increase=1.13, 95%: 1.03-1.24) was associated with an increased risk of death. The cumulative fluid output showed a U-shaped relationship with risk of death. Both lower output (adjusted per 1 L increase below 6.7 L=0.73, 95%: 0.58-0.90) and higher output (adjusted per 1 L increase above 6.7 L=1.24, 95%: 1.01-1.53) were associated with increased risk of death. In patients with CSA-AKI, excessive fluid input, insufficient or excessive output and a positive fluid balance or percentage of fluid overload change within the first 48 hours after CRRT initiation are associated with increased risk of 90-day mortality.
评估连续性肾脏替代治疗（CRRT）开始后48小时内的液体平衡与心脏手术相关急性肾损伤（CSA-AKI）患者90天死亡率之间的关联。前瞻性纳入2016年1月至2021年12月在南京医科大学第一附属医院因CSA-AKI接受CRRT超过24小时的成年患者。暴露因素为CRRT开始后48小时内的液体输入量、液体输出量、液体平衡及液体超负荷变化百分比（定义为体重标准化的液体输入/输出差值）。主要结局为90天死亡率。通过限制性立方样条和分段Cox回归确定暴露因素与90天死亡率之间的关系。该研究共纳入262例患者，90天死亡率为60.3%（158/262）。其中男性171例，女性91例，中位年龄为64（54，71）岁。死亡患者（=158例）在CRRT开始后48小时内的液体输入量更多[6.43（5.62，7.34）L对6.07（5.09，6.90）L，P=0.013]、液体平衡更大[-0.01（-1.36，1.34）L对-0.65（-1.71，0.42）L，P=0.005]且液体超负荷变化百分比更高[-0.01%（-2.17%，2.01%）对-0.85%（-2.49%，0.52%），P=0.013]，均高于存活患者（=104例）。累积液体平衡和液体超负荷变化与90天死亡率呈“J”形曲线关系。较高的正性液体平衡（每增加1L超过0.5L调整后HR=1.33，95%CI：1.17-1.50）和较大比例的液体超负荷变化（每增加1%超过0.7%调整后HR=1.20，95%CI：1.11-1.30）与死亡风险增加相关。累积液体输入量与90天死亡率呈线性相关。较高的输入量（每增加1L调整后HR=1.13，95%CI：1.03-1.24）与死亡风险增加相关。累积液体输出量与死亡风险呈U形关系。较低的输出量（每减少1L低于6.7L调整后HR=0.73，95%CI：0.58-0.90）和较高的输出量（每增加1L超过6.7L调整后HR=1.24，95%CI：1.01-1.53）均与死亡风险增加相关。在CSA-AKI患者中，CRRT开始后48小时内液体输入过多、输出不足或过多以及正性液体平衡或液体超负荷变化百分比与90天死亡风险增加相关。
