Association of Net Ultrafiltration Rate With Mortality Among Critically Ill Adults With Acute Kidney Injury Receiving Continuous Venovenous Hemodiafiltration A Secondary Analysis of the Randomized Evaluation of Normal vs Augmented Level (RENAL) of Renal Replacement Therapy Trial
Association of Net Ultrafiltration Rate With Mortality Among Critically Ill Adults With Acute Kidney Injury Receiving Continuous Venovenous Hemodiafiltration A Secondary Analysis of the Randomized Evaluation of Normal vs Augmented Level (RENAL) of Renal Replacement Therapy Trial
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DOI：
10.1001/jamanetworkopen.2019.5418
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发表时间：
2019-06-01
影响因子：
13.8
通讯作者：
Bellomo, Rinaldo
中科院分区：
文献类型：
--
作者：
Murugan, Raghavan;Kerti, Samantha J.;Bellomo, Rinaldo
重要性净超滤（NUF）经常用于治疗危重患者的液体超负荷，但NUF的发生率是否影响预后尚不清楚。目的研究NUF与接受连续性静脉-静脉血液透析滤过治疗的急性肾损伤危重患者的生存率之间的关系。和参与者肾脏替代治疗的正常水平与增强水平（RENAL）的随机评价试验于2005年12月30日至2008年11月28日进行，在澳大利亚和新西兰的35家重症监护室接受连续性静脉-静脉血液透析滤过治疗的急性肾损伤重症成人患者中。二次分析于2018年5月开始，2019年1月结束。暴露净超滤率，定义为根据患者体重调整的每小时清除的液体量。主要结局和指标风险调整后的90天生存率。结果在1434例患者中，年龄（四分位距）为67.3（56.9-76.3）岁; 924名参与者（64.4%）为男性;急性生理学和慢性健康评估III评分中位数（四分位距）为100（84-118）; 634名患者（44.2%）死亡。使用三分位数，定义了3组：高，NUF速率大于1.75 mL/kg/h;中，NUF速率为1.01 - 1.75 mL/kg/h;低，NUF速率小于1.01 mL/kg/h。与低三分位组相比，高三分位组与第0天至第6天的死亡无关。但有51名患者死亡（14.7%）在高三分位组vs 30例患者（8.6%）在低三分位组从第7天至第12天（校正风险比[aHR]，1.51; 95% CI，1.13-2.02）; 45例（15.3%）在高四分位组vs 25例患者（7.9%）在低三分位组中，从第13天到第26天（aHR，1.52; 95% CI，1.11-2.07）;从第27天到第90天，高三分位数组有48例患者（19.2%），低三分位数组有29例患者（9.9%）（aHR，1.66; 95%CI，1.16-2.39）。NUF速率每增加0.5 mL/kg/h，死亡率增加（3-6天：aHR，1.05; 95% CI，1.00-1.11; 7-12天：aHR，1.08; 95% CI，1.02-1.15; 13-26天：aHR，1.11; 95% CI，1.04-1.18; 27-90天：aHR，1.13; 95%CI，1.05-1.22）。采用纵向分析，NUF率的增加与较低的生存率相关（β = 0.056; P <0.001）。与中三分位组和低三分位组患者相比，高三分位组患者的低磷血症更常见（高：477例患者中有308例[64.6%];中：472例患者中有293例[62.1%];低：466例患者中有247例[53.0%]; P <0.001）。所有组均发生需要治疗的心律失常：高，176例患者（36.8%）;中度：175例患者（36.5%）;低：147例患者（30.8%）（P = .08）。结论和相关性在危重病人中，与低于1.01 mL/kg/h的NUF速率相比，高于1.75 mL/kg/h的NUF速率与较低的存活率相关。未测量的风险因素可能存在残余混杂，需要随机临床试验来证实这些发现。
IMPORTANCE Net ultrafiltration (NUF) is frequently used to treat fluid overload among critically ill patients, but whether the rate of NUF affects outcomes is unclear.OBJECTIVE To examine the association of NUF with survival among critically ill patients with acute kidney injury being treated with continuous venovenous hemodiafiltration.DESIGN, SETTING, AND PARTICIPANTS The Randomized Evaluation of Normal vs Augmented Level (RENAL) of Renal Replacement Therapy trial was conducted between December 30, 2005, and November 28, 2008, at 35 intensive care units in Australia and New Zealand among critically ill adults with acute kidney injury who were being treated with continuous venovenous hemodiafiltration. This secondary analysis began in May 2018 and concluded in January 2019.EXPOSURES Net ultrafiltration rate, defined as the volume of fluid removed per hour adjusted for patient body weight.MAIN OUTCOMES AND MEASURES Risk-adjusted 90-day survival.RESULTS Of 1434 patients, the median (interquartile range) age was 67.3 (56.9-76.3) years; 924 participants (64.4%) were male; median (interquartile range) Acute Physiology and Chronic Health Evaluation III score was 100 (84-118); and 634 patients (44.2%) died. Using tertiles, 3 groups were defined: high, NUF rate greater than 1.75 mL/kg/h; middle, NUF rate from 1.01 to 1.75 mL/kg/h; and low, NUF rate less than 1.01 mL/kg/h. The high-tertile group compared with the low-tertile group was not associated with death from day 0 to 6. However, death occurred in 51 patients (14.7%) in the high-tertile group vs 30 patients (8.6%) in the low-tertile group from day 7 to 12 (adjusted hazard ratio [aHR], 1.51; 95% CI, 1.13-2.02); 45 patients (15.3%) in the high-tertile group vs 25 patients (7.9%) in the low-tertile group from day 13 to 26 (aHR, 1.52; 95% CI, 1.11-2.07); and 48 patients (19.2%) in the high-tertile group vs 29 patients (9.9%) in the low-tertile group from day 27 to 90 (aHR, 1.66; 95% CI, 1.16-2.39). Every 0.5-mL/kg/h increase in NUF rate was associated with increased mortality (3-6 days: aHR, 1.05; 95% CI, 1.00-1.11; 7-12 days: aHR, 1.08; 95% CI, 1.02-1.15; 13-26 days: aHR, 1.11; 95% CI, 1.04-1.18; 27-90 days: aHR, 1.13; 95% CI, 1.05-1.22). Using longitudinal analyses, increase in NUF rate was associated with lower survival (beta = .056; P < .001). Hypophosphatemia was more frequent among patients in the high-tertile group compared with patients in the middle-tertile group and patients in the low-tertile group (high: 308 of 477 patients at risk [64.6%]; middle: 293 of 472 patients at risk [62.1%]; low: 247 of 466 patients at risk [53.0%]; P < .001). Cardiac arrhythmias requiring treatment occurred among all groups: high, 176 patients (36.8%); middle: 175 patients (36.5%); and low: 147 patients (30.8%) (P = .08).CONCLUSIONS AND RELEVANCE Among critically ill patients, NUF rates greater than 1.75 mL/kg/h compared with NUF rates less than 1.01 mL/kg/h were associated with lower survival. Residual confounding may be present from unmeasured risk factors, and randomized clinical trials are required to confirm these findings.