Timing of initiation of renal replacement therapy in sepsis-associated acute kidney injury
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摘要: 脓毒症相关急性肾损伤(SAKI)是重症监护室患者的常见并发症，是导致脓毒症病死率居高不下的独立危险因素，延长住院时间，带来高额医疗费用负担。SAKI与其他病因导致的AKI不一样，其发病机制更复杂，全身炎症反应发挥了重要作用，发展迅速，预后差。目前连续性肾脏替代疗法(CRRT)是ICU治疗SAKI的主要手段。但是启动CRRT的时机仍然存在争议，早期和晚期启动策略研究的结果相互矛盾。本文对SAKI患者启动CRRT时机的现有证据进行了全面综述。
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关键词:
- 连续性肾脏替代疗法 /
- 脓毒症相关急性肾损伤 /
- 启动时机
Abstract: Sepsis-associated acute kidney injury(SAKI) is a common complication in intensive care unit patients which is an independent risk factor leading to high mortality of sepsis, prolonged hospital stay, and high medical expenses. SAKI is different from acute kidney injury caused by other etiologies, which pathogenesis is more complex, and systemic inflammatory response plays an important role. SAKI deteriorates rapidly and has a poor prognosis. At present, continuous renal replacement therapy(CRRT) is the main treatment method for SAKI in ICU. The timing to start RRT, however, remains controversial, with early and late strategies providing conflicting results. This article provides a comprehensive review on the available evidence on the timing to start CRRT in patients with SAKI. -
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表 1 “早期”与“晚期”分组标准与研究结论比较
年份 作者 类型 样本量(早/晚) RRT模式 SAKI/% 早期组 晚期组 主要结论 2022[12] Yu等 回顾性 132 (58/74) CRRT 感染性休克合并心衰患者未发生AKI 感染性休克合并心衰患者已发生AKI 早期组的ICU病死率显著低于晚期组 2021[20] Chen等 回顾性 123 (72/51) CRRT 100.0 诊断AKI < 16 h 诊断AKI>16 h 早期组在30、60和90 d时的病死率均显著低于晚期组 2021[9] 甘伟忠等 多中心RCT 120 (61/59) CRRT 100.0 RIFLE受损期启动 RIFLE衰竭期启动 早期启动可改善SAKI的肾损伤程度 2020[19] Bagshaw (STARRT) 多中心RCT 2927 (1465/1462) 混合 57.7 KDIGO 2期或3期发病后12 h内 出现绝对适应证或少尿＞72 h以上 90 d病死率之间差异无统计学意义 2020[8] 吴相伟等 回顾性 244 (71 /173) CRRT 100.0 KDIGO 1、2期 KDIGO 3期 早期启动CRRT持续时间相对较短 2018[11] Lumlertgul等(FST试验) RCT 118 (58/60) CRRT 混合 速尿应激试验无反应后6 h内启动 出现适应证才开始使用 28 d生存率差异无统计学意义。FST实验有预测肾功能能力 2018[15] Barbar等 多中心，RCT 477 (239/238) 混合 100.0 RIFLE分期的F期12 h内 出现严重并发症、48 h肾功能无恢复 90 d病死率差异无统计学意义 2018[10] Srisawat等 RCT 40 (20/20) CRRT 72.5 PNGAL ≥ 400 ng/mL 12 h PNGAL ≥ 400 ng/mL，出现RRT的适应证 28 d病死率差异无统计学意义，PNGAL可以预测严重AKI 2016[16] Zarbock等(ELAIN实验) RCT 231 (112/119) CRRT 32.5 KDIGO诊断为AKI 2期并且血浆NGAL>150 ng/mL 8 h内 KOIGO诊断为AKI 3期后12 h内启动 早期开始显著降低90 d病死率 2016[17] Gaudry等(AKIKI实验) 多中心RCT 620 (211/308) 混合 66.7 KDIGO诊断为AKI 3期后6 h内开始 出现绝对适应证或少尿＞72 h以上 60 d病死率差异无统计学意义；早期策略组的导管相关血流感染率高于延迟策略组 
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