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[Lancet读者来信]:急性肾损伤的肾脏替代治疗
2021年01月26日 研究点评, 进展交流 暂无评论

CORRESPONDENCE|DECEMBER 19, 2020

Renal replacement therapy in acute kidney injury

Vincenzo Sepe, Teresa Rampino, Carmelo Libetta

Lancet 2020; 396: 1974 DOI:https://doi.org/10.1016/S0140-6736(20)32399-0

Stéphane Gaudry and colleagues1 found that early renal replacement therapy (RRT) in critically ill patients with acute kidney injury does not affect survival compared with a delayed RRT strategy. A major limitation of their meta-analysis is the clinical discretion on RRT timing and prescription. Furthermore, admission to intensive care units in the included studies allowed most patients with acute kidney injury to access treatment facilities, such as mechanical ventilation, which are not usually available in standard internal medicine or renal units. The Article1 shows no difference in 28-day mortality between groups receiving delayed and early RRT. However, only two of the eight included studies were carried out in renal units. These studies do not report the number of patients with chronic kidney disease and Kidney Disease: Improving Global Outcomes (KDIGO) category ,2 or acute kidney injury stage, and data are missing on residual diuresis. Additionally, details on drug treatment in the Article,1 such as the antibiotic therapy given to 525 of the 1205 patients with sepsis, have not been reported. Such clinical aspects have also not been reported in the included studies, adding relevant limitations to this meta-analysis.

Stéphane Gaudry及其同事发现,与延迟开始肾脏替代治疗(RRT)相比,发生急性肾损伤的危重病患者早期接受RRT并不影响生存率。这个meta分析的主要局限性之一是关于RRT的时机和处方的临床决策。而且,纳入的研究中要求患者收入ICU使得多数急性肾损伤患者有机会接受其他治疗措施如机械通气,而这些治疗措施在内科或肾脏内科病房并不具备。文章发现,接受延迟或早期RRT的患者28天病死率并无差异。然而,纳入的8项研究中仅有2项是在肾脏内科进行的。这些研究并没有报告慢性肾病及KDIGO分级的患者数,也没有报告急性肾损伤的分级,而且缺乏残余肾功能的数据。另外,文章中也没有报告药物治疗的细节,如1205名脓毒症患者中525名接受了抗生素治疗。纳入的研究也没有报告这些临床资料,从而增加了meta分析的局限性。

In our opinion, the message that RRT in patients with acute kidney injury “can be safely postponed”1 should be taken cautiously. Even more caution should be taken for patients with acute kidney injury admitted to standard medical units rather than to intensive care units.

从我们看来,有关急性肾损伤患者延迟RRT是安全的,这一结论应当谨慎对待。与收入ICU的急性肾损伤患者相比,对于收入内科病房的急性肾损伤患者,得出这一结论需要更加谨慎。

CORRESPONDENCE|DECEMBER 19, 2020

Renal replacement therapy in acute kidney injury

Zhenxing Lu, Beijing Yan, Kehu Yang, et al

Lancet 2020; 396: 1974-1975 DOI:https://doi.org/10.1016/S0140-6736(20)32405-3

Stéphane Gaudry and colleagues1 compared delayed versus early initiation of renal replacement therapy (RRT) in patients with severe acute kidney injury. One strength of this meta-analysis was the use of the Grading of Recommendations, Assessment, Development, and Evaluation to assess the certainty of evidence.23 Gaudry and colleagues1 rated 28-day mortality, 60-day mortality, and hospital mortality as patient outcomes with high certainty of evidence, and they concluded that mortality does not differ significantly according to whether RRT is initiated early or is delayed in patients with acute kidney injury. However, this conclusion might be modified when interpreting the results with absolute effect.

Stéphane Gaudry及其同事对严重急性肾损伤患者延迟与早期开始肾脏替代治疗(RRT)进行了比较。这个meta分析的优点之一在于使用GRADE评价证据的确定性。Gaudry及其同事将28天病死率,60天病死率及住院病死率作为反映患者预后的高确定性证据,从而得到结论即对于急性肾损伤患者,早期或延迟开始RRT时病死率并无显著差异。然而,当根据绝对效应进行结果解读时,这一结论可能有所改变。

Gaudry and colleagues1 considered the narrow confidence intervals of relative effects, in which both lower limits and upper limits were close to null effect (relative effect 1), and then did not rate down the certainty of evidence by imprecision. However, the absolute effect might suggest a different conclusion. The absolute difference in 28-day mortality between delayed RRT and early RRT ranged from 38 fewer deaths to 56 more deaths per 1000 patients (appendix). The lower limits indicate significant benefits of delayed RRT over early RRT, whereas the upper limits indicate an opposite result. Similar results were found for 60-day mortality and hospital mortality. By understanding the absolute effects, we might downgrade the certainty of evidence of the three mortality outcomes from high to moderate. Therefore, we are not sure whether the true effect of delayed RRT versus early RRT has an important clinical difference or not.

Gaudry及其同事认为,相对效应的可信区间很窄,即其上限和下限都与0效应(相对效应)非常接近,因而并没有因为缺乏精确性下调证据确定性等级。然而,绝对效应可能提示不同的结论。延迟与早期RRT组间28天病死率的绝对差异在每1000例患者少死亡38例到多死亡56例之间。其下限提示延迟RRT比早期RRT有显著获益,而上限提示完全相反的结果。60天病死率与住院病死率也得到相似结果。通过了解绝对效应,我们可能将上述3个病死率结局的证据确定性级别从高下调到中度。因而,我们并不确定延迟RRT较早期RRT的真正效应是否具有重要的临床差异。

To conclude, a conservative conclusion might be more appropriate to this study—the timing of RRT initiation might not affect survival in critically ill patients with severe acute kidney injury. Considering absolute effect could be helpful in interpreting the results of this study.1

总之,这个研究应当得到更加保守的结论,即开始RRT的时机可能不影响严重急性肾损伤的危重病患者的生存率。考虑绝对效应可能有助于解读这一研究的结果。

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