Timing of Renal Support and Outcome of Septic Shock and Acute Respiratory Distress Syndrome
Timing of Renal Support and Outcome of Septic Shock and Acute Respiratory Distress Syndrome
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肾支持的时机以及感染性休克和急性呼吸窘迫综合征的结果
DOI：
10.1164/rccm.201706-1255oc
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发表时间：
2018-07-01
影响因子：
24.7
通讯作者：
Dreyfuss, Didier
中科院分区：
文献类型：
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作者：
Gaudry, Stephane;Hajage, David;Dreyfuss, Didier
理论基础：感染性休克和急性呼吸窘迫综合征(ARDS)背景下的严重急性肾损伤患者启动肾脏替代疗法(RRT)的最佳策略尚不清楚。目的：根据基线脓毒症状态、ARDS状态和严重程度，比较早期和延迟启动RRT策略对60天死亡率的影响。方法：对Akiki(人工肾启动肾损伤)试验进行事后分析。测量和主要结果：根据基线特征定义亚组：脓毒症状态(败血症3定义)、ARDS状态(柏林定义)、简化急性生理学评分3(SAPS 3)、简化急性生理学评分3(SAPS 3和败血症相关器官衰竭评估(SOFA)。在619名患者中，348名(56%)有感染性休克，207名(33%)有ARDS。根据RRT启动策略，我们发现基线脓毒症状态(P=0.28)、基线ARDS状态(P=0.94)和基线严重程度评分(SAPS 3和SOFA分别为P=0.77和P=0.46)对60d死亡率的比较没有显著影响。延迟的RRT启动策略允许45%的感染性休克患者和46%的ARDS患者逃脱RRT。延迟组的尿量较高。感染性休克或急性呼吸窘迫综合征患者采用延迟RRT策略后肾功能恢复较早(分别为P=0.001和P=0.003)。ARDS患者的成功拔管时间不受RRT策略的影响(P=0.43)。结论：早期RRT策略与严重急性肾损伤合并感染性休克或ARDS患者60d死亡率的改善无关。在这些脆弱的人群中，通常可以避免不必要的和潜在的风险程序。
Rationale: The optimal strategy for initiation of renal replacement therapy (RRT) in patients with severe acute kidney injury in the context of septic shock and acute respiratory distress syndrome (ARDS) is unknown.Objectives: To examine the effect of an early compared with a delayed RRT initiation strategy on 60-day mortality according to baseline sepsis status, ARDS status, and severity.Methods: Post hoc analysis of the AKIKI (Artificial Kidney Initiation in Kidney Injury) trial.Measurements and Main Results: Subgroups were defined according to baseline characteristics: sepsis status (Sepsis-3 definition), ARDS status (Berlin definition), Simplified Acute Physiology Score 3 (SAPS 3), and Sepsis-related Organ Failure Assessment (SOFA). Of 619 patients, 348 (56%) had septic shock and 207 (33%) had ARDS. We found no significant influence of the baseline sepsis status (P = 0.28), baseline ARDS status (P = 0.94), and baseline severity scores (P = 0.77 and P = 0.46 for SAPS 3 and SOFA, respectively) on the comparison of 60-day mortality according to RRT initiation strategy. A delayed RRT initiation strategy allowed 45% of patients with septic shock and 46% of patients with ARDS to escape RRT. Urine output was higher in the delayed group. Renal function recovery occurred earlier with the delayed RRT strategy in patients with septic shock or ARDS (P, 0.001 and P = 0.003, respectively). Time to successful extubation in patients with ARDS was not affected by RRT strategy (P = 0.43).Conclusions: Early RRT initiation strategy was not associated with any improvement of 60-day mortality in patients with severe acute kidney injury and septic shock or ARDS. Unnecessary and potentially risky procedures might often be avoided in these fragile populations.