Donaldson Lachlan H, Devaux Anthony, White Kyle C, Rajbhandari Dorrilyn, Cohen Jeremy, Bellomo Rinaldo, Myburgh John, Hammond Naomi, Venkatesh Balasubramanian
The George Institute for Global Health, Faculty of Medicine, University of New South Wales, Sydney, Australia.
Malcolm Fisher Department of Intensive Care Medicine, Royal North Shore Hospital, St Leonards, Australia.
JAMA Netw Open. 2025 May 1;8(5):e2512279. doi: 10.1001/jamanetworkopen.2025.12279.
Sepsis-associated acute kidney injury (SA-AKI) is a common and clinically important condition in patients who are critically ill. Dysregulated inflammation may contribute to it. Intravenous hydrocortisone may decrease the risk of SA-AKI progression.
To describe the associations of hydrocortisone use with the incidence and outcomes of requirement for kidney replacement therapy (KRT), as well as source of sepsis, mean arterial pressure (MAP), and MAP indexed to required vasopressor (norepinephrine equivalent [NEE]).
DESIGN, SETTING, AND PARTICIPANTS: This cohort study was conducted as a post hoc analysis of the Adjunctive Corticosteroid Treatment in Critically Ill Patients with Septic Shock (ADRENAL) randomized clinical trial (RCT), a multicenter placebo-controlled RCT of hydrocortisone in patients with septic shock in 69 intensive care units in Australia, the United Kingdom, New Zealand, Saudi Arabia, and Denmark that recruited between 2013 and 2017. Participants were patients enrolled in the ADRENAL study with septic shock who did not require KRT in the 24 hours prior to randomization and who did not have a prior longstanding dialysis requirement. Data were analyzed between July and September 2024.
Receipt of hydrocortisone (vs placebo), MAP at enrollment, vasopressor dose (NEE) and MAP:NEE ratio, source of sepsis, causative organism, bacteremia, and the use of nephrotoxic antimicrobials, vasopressin, or specific inotropes.
Outcomes of interest were KRT requirement and liberation from KRT, measured as days alive and free of KRT.
A cohort of 3161 patients (median [IQR] age, 65 [53-74] years, 1921 [61%] male) was identified, including 1589 patients randomized to receive hydrocortisone and 1572 patients who received the placebo. Allocation to treatment with hydrocortisone was associated with a significantly reduced incidence of KRT requirement compared with placebo (329 patients [21%] vs 372 patients [24%]; odds ratio [OR], 0.84 [95% CI, 0.70 to 0.99]; P = .04). When controlled for factors associated with KRT requirement, randomization to hydrocortisone remained significantly associated with a reduced odds of new KRT requirement (OR, 0.79 [95% CI, 0.66 to 0.95]; P = .01). Among patients who started KRT following randomization, hydrocortisone was not associated with reduced days alive and free of KRT (mean difference, 1.28 [95% CI, -4.31 to 6.87] days; P = .65).
In this post hoc cohort study of patients with septic shock enrolled in a large RCT, intravenous hydrocortisone was associated with a reduced risk of new KRT requirement following randomization.
脓毒症相关急性肾损伤（SA-AKI）在重症患者中是一种常见且具有临床重要性的病症。炎症调节失调可能与之相关。静脉注射氢化可的松可能会降低SA-AKI进展的风险。
描述氢化可的松的使用与肾脏替代治疗（KRT）需求的发生率和结局、脓毒症来源、平均动脉压（MAP）以及与所需血管升压药（去甲肾上腺素当量[NEE]）相关的MAP之间的关联。
设计、设置和参与者：本队列研究是对重症脓毒症休克患者辅助性皮质类固醇治疗（ADRENAL）随机临床试验（RCT）进行的事后分析，这是一项在澳大利亚、英国、新西兰、沙特阿拉伯和丹麦的69个重症监护病房对脓毒症休克患者进行的氢化可的松多中心安慰剂对照RCT，该试验于2013年至2017年招募患者。参与者为参加ADRENAL研究的脓毒症休克患者，这些患者在随机分组前24小时内不需要KRT且既往没有长期透析需求。数据于2024年7月至9月进行分析。
接受氢化可的松（与安慰剂相比）、入组时的MAP、血管升压药剂量（NEE）和MAP:NEE比值、脓毒症来源、致病微生物、菌血症以及使用肾毒性抗菌药物、血管加压素或特定的正性肌力药物。
感兴趣的结局为KRT需求和脱离KRT，以存活且无KRT的天数来衡量。
确定了一个由3161名患者组成的队列（年龄中位数[四分位间距]为65[53 - 74]岁，1921名[61%]为男性），其中1589名患者随机接受氢化可的松治疗，1572名患者接受安慰剂治疗。与安慰剂相比，分配接受氢化可的松治疗与KRT需求发生率显著降低相关（329名患者[21%]对372名患者[24%]；比值比[OR]，0.84[95%置信区间，0.70至0.99]；P = 0.04）。在控制了与KRT需求相关的因素后，随机接受氢化可的松治疗仍与新的KRT需求几率降低显著相关（OR，0.79[95%置信区间，0.66至0.95]；P = 0.01）。在随机分组后开始KRT的患者中（平均差异，1.28[95%置信区间，-4.31至6.87]天；P = 0.65）。
在这项对纳入大型RCT的脓毒症休克患者进行的事后队列研究中，静脉注射氢化可的松与随机分组后新的KRT需求风险降低相关。
