Zhao Chen Long, Zhao Meng Ya, Wang Hao, Zhi De Yuan, Ji Xiao Jun, Duan Mei Li, Lin Jin
Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, China.
Department of Clinical Epidemiology and Evidence-Based Medicine, National Clinical Research Center for Digestive Disease, Beijing Friendship Hospital, Capital Medical University.
Ren Fail. 2025 Dec;47(1):2511277. doi: 10.1080/0886022X.2025.2511277. Epub 2025 May 29.
Net ultrafiltration (NUF) rates correlate with outcomes in critically ill patients on continuous renal replacement therapy (CRRT), but optimal strategies for septic acute kidney injury (AKI) are unclear. This study evaluated early NUF rates and survival in septic AKI.
A retrospective cohort of 219 adults with septic AKI requiring CRRT at a tertiary ICU was analyzed. Early NUF (weight-adjusted fluid removal/hour during the first 48 h of CRRT) was stratified into low- (<1.22 mL/kg/h), moderate- (1.22-1.79 mL/kg/h), and high-intensity (>1.79 mL/kg/h) groups. The primary outcome was 28-day mortality. Associations were assessed using multivariable Cox regression and restricted cubic spline models, adjusted for demographics, severity scores, fluid balance, and biomarkers.
The high-intensity group had the highest 28-day mortality (68.5% vs. 43.8% moderate vs. 45.2% low). High-intensity NUF was independently associated with increased mortality vs. moderate (adjusted HR = 1.88, 95% CI:1.19-2.97, = 0.007) and low-intensity groups (adjusted HR = 2.01, 95% CI:1.25-3.22, = 0.004). Nonlinear analysis demonstrated a nonlinear relationship, with risks escalating steeply at rates above 1.79 mL/kg/h.
High-intensity NUF during early CRRT was associated with higher mortality in patients with septic AKI mortality, particularly among those with high severity of illness. Moderate NUF had lowest mortality, suggesting that intermediate NUF rates may best balance the competing risks of worsening hemodynamic instability from excess NUF and persistent volume overload from inadequate NUF. However, future trials are needed to better define the optimal approach to NUF in patients with septic AKI.
在接受持续肾脏替代治疗（CRRT）的危重症患者中，净超滤（NUF）率与预后相关，但脓毒症急性肾损伤（AKI）的最佳治疗策略尚不清楚。本研究评估了脓毒症AKI患者的早期NUF率和生存率。
对一家三级重症监护病房（ICU）中219例需要CRRT的脓毒症AKI成年患者进行回顾性队列分析。早期NUF（CRRT开始后48小时内体重调整后的每小时液体清除量）分为低强度组（<1.22 mL/kg/h）、中等强度组（1.22 - 1.79 mL/kg/h）和高强度组（>1.79 mL/kg/h）。主要结局是28天死亡率。采用多变量Cox回归和受限立方样条模型评估相关性，并对人口统计学、严重程度评分、液体平衡和生物标志物进行了调整。
高强度组的28天死亡率最高（68.5%，中等强度组为43.8%，低强度组为45.2%）。与中等强度组（调整后风险比[HR]=1.88，95%置信区间[CI]：1.19 - 2.97，P = 0.007）和低强度组相比，高强度NUF与死亡率增加独立相关（调整后HR = 2.01，95% CI：1.25 - 3.22，P = 0.004）。非线性分析显示存在非线性关系，当速率高于1.79 mL/kg/h时风险急剧上升。
早期CRRT期间的高强度NUF与脓毒症AKI患者的较高死亡率相关，尤其是在病情严重程度较高的患者中。中等强度的NUF死亡率最低，这表明中等NUF率可能最能平衡因过度NUF导致的血流动力学不稳定恶化和因NUF不足导致的持续容量超负荷这两种相互竞争的风险。然而，未来需要进行试验以更好地确定脓毒症AKI患者NUF的最佳方法。
