小柯机器人

法国巴黎大学Didier Dreyfuss课题组探讨了延迟和早期开始肾脏替代治疗对严重急性肾损伤患者的影响。2020年4月23日出版的《柳叶刀》发表了这项成果。

在没有危及生命的并发症的情况下，严重急性肾损伤的肾脏替代治疗（RRT）时机备受争议。研究组评估了延迟和早期RRT启动方案对严重急性肾损伤患者28天生存率的影响。

在这项系统回顾和患者数据的荟萃分析中，研究组从MEDLINE、Embase和Cochrane对照试验中心数据库中检索从2008年4月1日至2019年12月20日进行的随机试验，比较了严重急性肾损伤患者的延迟和早期RRT启动方案的效果。

共有10项研究（包括2143名患者）被纳入最终分析。9项研究（2083名患者）的患者数据可用，其中1879名患者有严重急性肾损伤，接受随机分配，其中946名纳入延迟RRT组，933名纳入早期RRT组。延迟RRT组28天死亡率为44%，早期RRT组为43%，差异无统计学意义。各研究之间没有异质性，大多数研究具有较低的偏倚风险。

总之，在没有RRT紧急指征的情况下，RRT启动时机并不影响严重急性肾损伤患者的生存率。延迟RRT的启动，并密切监测患者，可减少RRT的使用，节省医疗资源。

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

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