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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:
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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]. 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]. 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
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