切换至 "中华医学电子期刊资源库"
高级检索
中华危重症医学杂志(电子版)

中华危重症医学杂志(电子版) ›› 2020, Vol. 13 ›› Issue (05) : 356 -363. doi: 10.3877/cma.j.issn.1674-6880.2020.05.007

所属专题： 文献；

荟萃分析

肾脏替代治疗启动时机对成人急性肾损伤患者预后影响的Meta分析
徐冬雪1, 蒋芳1, 张晓艺1, 柳叶1, 彭志勇1,†()   
  1. 1. 430071　武汉，武汉大学中南医院重症医学科
  • 收稿日期:2020-09-19 出版日期:2020-10-31
  • 通信作者: 彭志勇
  • 基金资助:
    国家自然科学基金项目(81772046); 湖北省科技计划项目(2017AHB044)

Effect of renal replacement therapy timing on prognosis of adult patients with acute kidney injury: a meta-analysis

Dongxue Xu1, Fang Jiang1, Xiaoyi Zhang1, Ye Liu1, Zhiyong Peng1,†()   

  1. 1. Department of Critical Care Medicine, Zhongnan Hospital of Wuhan University, Wuhan 430071, China
  • Received:2020-09-19 Published:2020-10-31
  • Corresponding author: Zhiyong Peng
  • About author:
    Corresponding author: Peng Zhiyong, Email:
全文 ( ) 下载PDF ( ) 导出引用
引用本文：

徐冬雪, 蒋芳, 张晓艺, 柳叶, 彭志勇. 肾脏替代治疗启动时机对成人急性肾损伤患者预后影响的Meta分析[J/OL]. 中华危重症医学杂志(电子版), 2020, 13(05): 356-363.

Dongxue Xu, Fang Jiang, Xiaoyi Zhang, Ye Liu, Zhiyong Peng. Effect of renal replacement therapy timing on prognosis of adult patients with acute kidney injury: a meta-analysis[J/OL]. Chinese Journal of Critical Care Medicine(Electronic Edition), 2020, 13(05): 356-363.

目的

系统评估启用肾脏替代治疗（RRT）时机对成人急性肾损伤（AKI）患者预后的影响。

方法

计算机检索PubMed、The Cochrane Library、Embase数据库从建库至2019年2月发表的关于成人AKI患者启用RRT时机的临床随机对照研究（RCT）。由2位研究者按照纳入及排除标准独立进行文献筛选、资料提取及质量评价，采用Revman 5.3软件进行Meta分析。

结果

共纳入11个RCT，包括2 332例AKI患者。Meta分析显示，早期与晚期启动RRT治疗的AKI患者间总病死率[相对危险度（RR）= 0.92，95%置信区间（CI）（0.78，1.09），Z = 5.53，P = 0.35]、14 d病死率[RR = 0.84，95%CI（0.66，1.07），Z = 1.40，P = 0.16]、30 d病死率[RR = 0.98，95%CI（0.83，1.10），Z = 0.40，P = 0.69]、60 d病死率[RR = 0.97，95%CI（0.87，1.07），Z = 0.67，P = 0.50]、90 d病死率[RR = 1.00，95%CI（0.89，1.12），Z = 0.01，P = 0.99]、ICU住院时间[标准均数差（SMD）= -0.08，95%CI（-0.18，0.02），Z = 1.63，P = 0.10]以及总住院时间[SMD = -0.16，95%CI（-0.32，0.00），Z = 1.96，P = 0.05]的比较，差异均无统计学意义。

结论

早期RRT治疗不能改善成人AKI患者的预后。

关键词: 急性肾损伤, 肾脏替代治疗, 启动时机, 预后, Meta分析
Objective

To evaluate the effect of renal replacement therapy (RRT) timing on the prognosis of adult patients with acute kidney injury (AKI).

Methods

Systematic searches were conducted in the PubMed, Cochrane Library and Embase database to collect randomized controlled trials (RCTs) about the early and delayed initiation of RRT for adult patients with AKI published up to February 2019. Two reviewers independently screened articles according to the inclusion and exclusion criteria, extracted data and evaluated the quality of the included studies. Meta-analysis was conducted using the Revman 5.3 software.

Results

Eleven RCTs involving 2 332 AKI patients were enrolled. Meta-analysis demonstrated that the total mortality [risk ratio (RR) = 0.92, 95% confidence interval (CI) (0.78, 1.09), Z = 5.53, P = 0.35], 14 d mortality [RR = 0.84, 95%CI (0.66, 1.07), Z = 1.40, P = 0.16], 30 d mortality [RR = 0.98, 95%CI (0.83, 1.10) , Z = 0.40, P = 0.69], 60 d mortality [RR = 0.97, 95%CI (0.87, 1.07), Z = 0.67, P = 0.50], 90 d mortality [RR = 1.00, 95%CI (0.89, 1.12), Z = 0.01, P = 0.99], ICU stay[standardized mean difference (SMD) = -0.08, 95%CI (-0.18, 0.02), Z = 1.63, P = 0.10] and hospital stay [SMD = -0.16, 95%CI (-0.32, 0.00), Z = 1.96, P = 0.05] were not significantly different between AKI patients with the early and delayed initiation of RRT.

Conclusion

Early initiation of RRT cannot improve the prognosis of adult patients with AKI.

Key words: Acute kidney injury, Renal replacement therapy, Timing, Prognosis, Meta-analysis
表1 早期和晚期启动RRT的定义
纳入文献 早期RRT 晚期RRT
Gaudry等[8] KDIGO诊断为AKI 3期后6 h内开始 至少符合以下标准之一：严重高钾血症、代谢性酸中毒、肺水肿、血尿素氮水平高于1 120 mg/L或随机化后少尿72 h以上
Bouman等[10] 纳入后12 h内开始 常规的RRT标准
Durmaz等[11] 冠状动脉旁路移植术前预防性血液透析 冠状动脉旁路移植术后血液透析
Sugahara等[12] 当尿量降至30 mL/h以下时开始接受透析治疗的患者 冠状动脉旁路移植术后14 d，直到尿量小于20 mL/h才开始透析治疗
Liu等[13] 血尿素氮<760 mg/L 血尿素氮>760 mg/L
Payen等[14] 诊断为脓毒症后立即启动 常规的RRT标准
Wald等[15] 患者在符合资格后12 h内开始 患者在符合资格后平均31.6 h开始
Comes等[16] 心脏手术后24 h内有持续的术后休克 常规的RRT标准
Zarbock等[17] KDIGO诊断为AKI 2期后8 h内启动 KOIGO诊断为AKI 3期后12 h内启动
Barbar等[18] AKI发病后12 h内开始 AKI发病后48 h肾功能没有恢复
Jamale等[19] 血清尿素氮和（或）肌酐水平分别升到700 mg/L和70 mg/L 常规的RRT标准
图1 纳入研究的方法学质量评价
表2 纳入文献的基本特征
纳入文献 年龄（岁， ± s） 样本量（例） SOFA评分（分， ± s） APACHEⅡ评分（分， ± s）
早期RRT 晚期RRT 早期RRT 晚期RRT 早期RRT 晚期RRT
Gaudry等[8] 66.1 ± 13.9 311 308 10.9 ± 3.2 10.8 ± 3.1 - -
Bouman等[10] 62.1 ± 16.6 35 36 10.1 ± 2.2 10.6 ± 1.9 21.7 ± 5.5 23.6 ± 8.3
Durmaz等[11] 56.1 ± 11.5 21 23 - - - -
Sugahara等[12] 64.5 ± 2.5 14 14 - - 18 ± 3 19 ± 2
Liu等[13] 56.0 ± 2.2 122 121 - - - -
Payen等[14] 58.1 ± 13.0 37 39 54.3 ± 7.3 52.4 ± 7.5 11.6 ± 3.4 10.4 ± 2.9
Wald等[15] 63.1 ± 12.8 48 52 12.0 ± 3.3 11.9 ± 2.0 - -
Comes等[16] 59.0 ± 15.1 112 112 11.5 ± 2.8 12.0 ± 2.9 - -
Zarbock等[17] 67.0 ± 13.1 112 119 15.6 ± 2.3 16.0 ± 2.3 30.6 ± 7.5 32.7 ± 8.8
Barbar等[18] 69.0 ± 12.2 246 242 12.2 ± 2.9 12.4 ± 2.9 - -
Jamale等[19] 42.4 ± 15.3 102 106 7.6 ± 3.3 8.2 ± 3.1 - -
图2 不同RRT时机对成人AKI患者总体病死率影响的森林图
图3 不同RRT时机对成人AKI患者14 d病死率影响的森林图
图4 不同RRT时机对成人AKI患者30 d病死率影响的森林图
图5 不同RRT时机对成人AKI患者60 d病死率影响的森林图
图6 不同RRT时机对成人AKI患者90 d病死率影响的森林图
图7 不同RRT时机对成人AKI患者ICU住院时间影响的森林图
图8 不同RRT时机对成人AKI患者总住院时间影响的森林图
1
黄曼，耿婷婷. 急性肾损伤的研究进展[J]. 中华急诊医学杂志，2017，26(9): 986-991.
2
Hoste EA, Bagshaw SM, Bellomo R, et al. Epidemiology of acute kidney injury in critically ill patients: the multinational AKI-EPI study[J]. Intensive Care Med, 2015, 41 (8): 1411-1423.
3
Bagshaw SM, Goldstein SL, Ronco C, et al. Acute kidney injury in the era of big data: the 15 (th) Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) [J]. Can J Kidney Health Dis, 2016 (3): 5.
4
Clec'h C, Gonzalez F, Lautrette A, et al. Multiple-center evaluation of mortality associated with acute kidney injury in critically ill patients: a competing risks analysis[J]. Crit Care, 2011. 15 (3): R128.
5
陈敏华，孙仁华，李茜. 传统肾脏替代治疗开始指标在判断重症急性肾损伤患者预后的价值[J]. 中华急诊医学杂志，2016，25(2): 182-189.
6
吴灵萍，张萍，蒋华，等. ICU急性肾损伤患者连续肾脏替代疗法临床分析[J/CD]. 中华危重症医学杂志（电子版），2017，10(5): 322-327.
7
Yang XM, Tu GW, Gao J, et al. A comparison of preemptive versus standard renal replacement therapy for acute kidney injury after cardiac surgery[J]. J Surg Res, 2016, 204 (1): 205-212.
8
Gaudry S, Hajage D, Schortgen F, et al. Initiation strategies for renal-replacement therapy in the intensive care unit[J]. N Engl J Med, 2016, 375 (2): 122-133.
9
Hoste EA, Clermont G, Kersten A, et al. RIFLE criteria for acute kidney injury are associated with hospital mortality in critically ill patients: a cohort analysis[J]. Crit Care, 2006, 10 (3): R73.
10
Bouman CS, Oudemans-Van Straaten HM, Tijssen JG, et al. Effects of early high-volume continuous venovenous hemofiltration on survival and recovery of renal function in intensive care patients with acute renal failure: a prospective, randomized trial[J]. Crit Care Med, 2002, 30 (10): 2205-2211.
11
Durmaz I, Yagdi T, Calkavur T, et al. Prophylactic dialysis in patients with renal dysfunction undergoing on-pump coronary artery bypass surgery[J]. Ann Thorac Surg, 2003, 75 (3): 859-864.
12
Sugahara S, Suzuki H. Early start on continuous hemodialysis therapy improves survival rate in patients with acute renal failure following coronary bypass surgery[J]. Hemodial Int, 2004, 8 (4): 320-325.
13
Liu KD, Himmelfarb J, Paganini E, et al. Timing of initiation of dialysis in critically ill patients with acute kidney injury[J]. Clin J Am Soc Nephrol, 2006, 1 (5): 915-919.
14
Payen D, Mateo J, Cavaillon JM, et al. Impact of continuous venovenous hemofiltration on organ failure during the early phase of severe sepsis: a randomized controlled trial[J]. Crit Care Med, 2009, 37 (3): 803-810.
15
Wald R, Adhikari NK, Smith OM, et al. Comparison of standard and accelerated initiation of renal replacement therapy in acute kidney injury[J]. Kidney Int, 2015, 88 (4): 897-904.
16
Combes A, Bréchot N, Amour J, et al. Early high-volume hemofiltration versus standard care for post-cardiac surgery shock. The HEROICS study[J]. Am J Respir Crit Care Med, 2015, 192 (10): 1179-1190.
17
Zarbock A, Kellum JA, Schmidt C, et al. Effect of early vs delayed initiation of renal replacement therapy on mortality in critically ill patients with acute kidney injury: the ELAIN randomized clinical trial[J]. JAMA, 2016, 315 (20): 2190-2199.
18
Barbar SD, Clere-Jehl R, Bourredjem A, et al. Timing of renal-replacement therapy in patients with acute kidney injury and sepsis[J]. N Engl J Med, 2018, 379 (15): 1431-1442.
19
Jamale TE, Hase NK, Kulkarni M, et al. Earlier-start versus usual-start dialysis in patients with community-acquired acute kidney injury: a randomized controlled trial[J]. Am J Kidney Dis, 2013, 62 (6): 1116-1121.
20
Bellomo R, Kellum JA, Ronco C. Acute kidney injury[J]. Lancet, 2012, 380 (9843): 756-766.
21
Uchino S, Kellum JA, Bellomo R, et al. Acute renal failure in critically ill patients: a multinational, multicenter study[J]. JAMA, 2005, 294 (7): 813-818.
22
Basu RK, Wang Y, Wong HR, et al. Incorporation of biomarkers with the renal angina index for prediction of severe AKI in critically ill children[J]. Clin J Am Soc Nephrol, 2014, 9 (4): 654-662.
23
陈敏华，孙仁华，李茜. 脓毒症伴急性肾损伤患者连续性肾脏替代治疗时机的探讨[J/CD]. 中华危重症医学杂志（电子版），2016，9(3): 149-153.
24
Sawhney S, Marks A, Fluck N, et al. Acute kidney injury as an independent risk factor for unplanned 90-day hospital readmissions[J]. BMC Nephrol, 2017, 18 (1): 9.
25
龚晓莹，王睿，李国福. 肾脏替代治疗开始时机对脓毒症急性肾损伤患者预后影响的Meta分析[J]. 中华危重病急救医学，2015，27(9): 712-717.
26
Wang C, Lv LS, Huang H, et al. Initiation time of renal replacement therapy on patients with acute kidney injury: a systematic review and meta-analysis of 8179 participants[J]. Nephrology (Carlton), 2017, 22 (1): 7-18.
27
Yang XM, Tu GW, Zheng JL, et al. A comparison of early versus late initiation of renal replacement therapy for acute kidney injury in critically ill patients: an updated systematic review and meta-analysis of randomized controlled trials[J]. BMC Nephrol, 2017, 18 (1): 264.
[1] 张晓宇, 殷雨来, 张银旭. 阿帕替尼联合新辅助化疗对三阴性乳腺癌的疗效及预后分析[J/OL]. 中华乳腺病杂志(电子版), 2024, 18(06): 346-352.
[2] 许杰, 李亚俊, 韩军伟. 两种入路下腹腔镜根治性全胃切除术治疗超重胃癌的效果比较[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 19-22.
[3] 高杰红, 黎平平, 齐婧, 代引海. ETFA和CD34在乳腺癌中的表达及与临床病理参数和预后的关系研究[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 64-67.
[4] 李代勤, 刘佩杰. 动态增强磁共振评估中晚期低位直肠癌同步放化疗后疗效及预后的价值[J/OL]. 中华普外科手术学杂志(电子版), 2025, 19(01): 100-103.
[5] 屈翔宇, 张懿刚, 李浩令, 邱天, 谈燚. USP24及其共表达肿瘤代谢基因在肝细胞癌中的诊断和预后预测作用[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(06): 659-662.
[6] 顾雯, 凌守鑫, 唐海利, 甘雪梅. 两种不同手术入路在甲状腺乳头状癌患者开放性根治性术中的应用比较[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(06): 687-690.
[7] 付成旺, 杨大刚, 王榕, 李福堂. 营养与炎症指标在可切除胰腺癌中的研究进展[J/OL]. 中华普外科手术学杂志(电子版), 2024, 18(06): 704-708.
[8] 李伟, 宋子健, 赖衍成, 周睿, 吴涵, 邓龙昕, 陈锐. 人工智能应用于前列腺癌患者预后预测的研究现状及展望[J/OL]. 中华腔镜泌尿外科杂志(电子版), 2024, 18(06): 541-546.
[9] 关小玲, 周文营, 陈洪平. PTAAR在乙肝相关慢加急性肝衰竭患者短期预后中的预测价值[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 841-845.
[10] 张润锦, 阳盼, 林燕斯, 刘尊龙, 刘建平, 金小岩. EB病毒相关胆管癌伴多发转移一例及国内文献复习[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 865-869.
[11] 陈晓鹏, 王佳妮, 练庆海, 杨九妹. 肝细胞癌VOPP1表达及其与预后的关系[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(06): 876-882.
[12] 董佳, 王坤, 张莉. 预后营养指数结合免疫球蛋白、血糖及甲胎蛋白对HBV 相关慢加急性肝衰竭患者治疗后预后不良的预测价值[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(06): 555-559.
[13] 王景明, 王磊, 许小多, 邢文强, 张兆岩, 黄伟敏. 腰椎椎旁肌的研究进展[J/OL]. 中华临床医师杂志(电子版), 2024, 18(09): 846-852.
[14] 颜世锐, 熊辉. 感染性心内膜炎合并急性肾损伤患者的危险因素探索及死亡风险预测[J/OL]. 中华临床医师杂志(电子版), 2024, 18(07): 618-624.
[15] 郭曌蓉, 王歆光, 刘毅强, 何英剑, 王立泽, 杨飏, 汪星, 曹威, 谷重山, 范铁, 李金锋, 范照青. 不同亚型乳腺叶状肿瘤的临床病理特征及预后危险因素分析[J/OL]. 中华临床医师杂志(电子版), 2024, 18(06): 524-532.
阅读次数
全文


摘要

版权所有 中华医学会 中华医学电子音像出版社有限责任公司  京ICP备14006079号-1  网络出版服务许可证：(署)网出证(京)字第075号