嚴重急性腎損傷患者延遲或早期腎臟替代治療對生存率無影響

嚴重急性腎損傷患者延遲或早期腎臟替代治療對生存率無影響

作者：

小柯機器人

發布時間：2020/4/26 13:57:45

法國巴黎大學Didier Dreyfuss課題組探討了延遲和早期開始腎臟替代治療對嚴重急性腎損傷患者的影響。2020年4月23日出版的《柳葉刀》發表了這項成果。

在沒有危及生命的併發症的情況下，嚴重急性腎損傷的腎臟替代治療（RRT）時機備受爭議。研究組評估了延遲和早期RRT啟動方案對嚴重急性腎損傷患者28天生存率的影響。

在這項系統回顧和患者數據的薈萃分析中，研究組從MEDLINE、Embase和Cochrane對照試驗中心資料庫中檢索從2008年4月1日至2019年12月20日進行的隨機試驗，比較了嚴重急性腎損傷患者的延遲和早期RRT啟動方案的效果。

共有10項研究（包括2143名患者）被納入最終分析。9項研究（2083名患者）的患者數據可用，其中1879名患者有嚴重急性腎損傷，接受隨機分配，其中946名納入延遲RRT組，933名納入早期RRT組。延遲RRT組28天死亡率為44%，早期RRT組為43%，差異無統計學意義。各研究之間沒有異質性，大多數研究具有較低的偏倚風險。

總之，在沒有RRT緊急指徵的情況下，RRT啟動時機並不影響嚴重急性腎損傷患者的生存率。延遲RRT的啟動，並密切監測患者，可減少RRT的使用，節省醫療資源。

附：英文原文

Title: Delayed versus early initiation of renal replacement therapy for severe acute kidney injury: a systematic review and individual patient data meta-analysis of randomised clinical trials

Author: Stéphane Gaudry, David Hajage, Nicolas Benichou, Khalil Chabi, Saber Barbar, Alexander Zarbock, Nuttha Lumlertgul, Ron Wald, Sean M Bagshaw, Nattachai Srisawat, Alain Combes, Guillaume Geri, Tukaram Jamale, Agnès Dechartres, Jean-Pierre Quenot, Didier Dreyfuss

Issue&Volume: 2020-04-23

Abstract: Background

The timing of renal replacement therapy (RRT) for severe acute kidney injury is highly debated when no life-threatening complications are present. We assessed whether a strategy of delayed versus early RRT initiation affects 28-day survival in critically ill adults with severe acute kidney injury.

Methods

In this systematic review and individual patient data meta-analysis, we searched MEDLINE (via PubMed), Embase, and the Cochrane Central Register of Controlled Trials for randomised trials published from April 1, 2008, to Dec 20, 2019, that compared delayed and early RRT initiation strategies in patients with severe acute kidney injury. Trials were eligible for inclusion if they included critically ill patients aged 18 years or older with acute kidney injury (defined as a Kidney Disease: Improving Global Outcomes [KDIGO] acute kidney injury stage 2 or 3, or, where KDIGO was unavailable, a renal Sequential Organ Failure Assessment score of 3 or higher). We contacted the principal investigator of each eligible trial to request individual patient data. From the included trials, any patients without acute kidney injury or who were not randomly allocated were not included in the individual patient data meta-analysis. The primary outcome was all-cause mortality at day 28 after randomisation. This study is registered with PROSPERO (CRD42019125025).

Findings

Among the 1031 studies identified, one study that met the eligibility criteria was excluded because the recruitment period was not recent enough, and ten (including 2143 patients) were included in the analysis. Individual patient data were available for nine studies (2083 patients), from which 1879 patients had severe acute kidney injury and were randomly allocated: 946 (50%) to the delayed RRT group and 933 (50%) to the early RRT group. 390 (42%) of 929 patients allocated to the delayed RRT group and who had available data did not receive RRT. The proportion of patients who died by day 28 did not significantly differ between the delayed RRT group (366 [44%] of 837) and the early RRT group (355 [43%] of 827; risk ratio 1·01 [95% CI 0·91 to 1·13], p=0·80), corresponding to an overall risk difference of 0·01 (95% CI 0·04 to 0·06). There was no heterogeneity across studies ( I 2=0%; τ 2=0), and most studies had a low risk of bias.

Interpretation

The timing of RRT initiation does not affect survival in critically ill patients with severe acute kidney injury in the absence of urgent indications for RRT. Delaying RRT initiation, with close patient monitoring, might lead to a reduced use of RRT, thereby saving health resources.

DOI: 10.1016/S0140-6736(20)30531-6

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(20)30531-6/fulltext