Acute kidney injury in patients with acute lung injury: impact of fluid accumulation on classification of acute kidney injury and associated outcomes.
Acute kidney injury in patients with acute lung injury: impact of fluid accumulation on classification of acute kidney injury and associated outcomes.
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DOI：
10.1097/ccm.0b013e318228234b
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发表时间：
2011-12
影响因子：
8.8
通讯作者：
National Institutes of Health National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network
中科院分区：
文献类型：
--
作者：
Liu KD;Thompson BT;Ancukiewicz M;Steingrub JS;Douglas IS;Matthay MA;Wright P;Peterson MW;Rock P;Hyzy RC;Anzueto A;Truwit JD;National Institutes of Health National Heart, Lung, and Blood Institute Acute Respiratory Distress Syndrome Network
已经表明，液体积聚可能延迟急性肾损伤（阿基）的识别。我们试图确定液体平衡对急性肺损伤患者非透析阿基发生率的影响，并描述相关结局，包括死亡率。液体和导管治疗试验的分析，保守与自由液体管理以及中心静脉导管与肺动脉导管引导的管理的析因随机临床试验。1000名患者在ARDS网络医院。阿基的发生率定义为48小时内肌酐绝对升高≥ 0.3 mg/dL或相对变化> 50%，在调整血清肌酐以实现液体平衡之前和之后进行检查。在调整液体平衡之前，采用保守液体方案治疗的患者中阿基的发生率更高（57 vs 51%，p = 0.04）。在调整液体平衡后，采用自由液体方案管理的患者阿基的发生率更高（66 vs 58%，p = 0.007）。在调整肌酐以实现液体平衡后（但不是之前）符合阿基标准的患者的死亡率显著高于在调整液体平衡前后均不符合阿基标准的患者（31 vs 12%，p < 0.001）和在调整液体平衡之前但不是之后发生阿基的患者（31 vs 11%，p = 0.005）。在调整液体平衡后而非调整前符合阿基标准的患者的死亡率与调整液体平衡前后的阿基患者相似（31% vs 38%，p = 0.18）。液体管理影响血清肌酐，因此使用基于肌酐的定义诊断阿基。在调整液体正平衡后发现的“未识别”阿基患者的死亡率较高，在调整液体平衡之前但之后未发现阿基的患者的死亡率较低。阿基的未来研究应考虑液体平衡变化引起的血清肌酐的潜在差异以及这些差异对诊断和预后的影响。
It has been suggested that fluid accumulation may delay recognition of acute kidney injury (AKI). We sought to determine the impact of fluid balance on the incidence of non-dialysis requiring AKI in patients with acute lung injury and to describe associated outcomes, including mortality. Analysis of the Fluid and Catheter Treatment Trial, a factorial randomized clinical trial of conservative versus liberal fluid management and of management guided by a central venous versus pulmonary artery catheter. 1000 patients at ARDS Network hospitals. The incidence of AKI, defined as an absolute rise in creatinine of ≥ 0.3 mg/dL or a relative change of > 50% over 48 hours, was examined before and after adjustment of serum creatinine for fluid balance. The incidence of AKI before adjustment for fluid balance was greater in those managed with the conservative fluid protocol (57 versus 51%, p = 0.04). After adjustment for fluid balance, the incidence of AKI was greater in those managed with the liberal fluid protocol (66 versus 58%, p = 0.007). Patients who met AKI criteria after adjustment of creatinine for fluid balance (but not before) had a mortality rate that was significantly greater than those who did not meet AKI criteria both before and after adjustment for fluid balance (31 versus 12%, p < 0.001) and those who had AKI before but not after adjustment for fluid balance (31 versus 11%, p = 0.005). The mortality of those patients meeting AKI criteria after but not before adjustment for fluid balance was similar to patients with AKI both before and after adjustment for fluid balance (31% versus 38%, p = 0.18). Fluid management influences serum creatinine and therefore the diagnosis of AKI using creatinine-based definitions. Patients with “unrecognized” AKI that is identified after adjusting for positive fluid balance have high mortality rates, and patients who have AKI before but not after adjusting for fluid balance have low mortality rates. Future studies of AKI should consider potential differences in serum creatinine caused by changes in fluid balance and the impact of these differences on diagnosis and prognosis.