CORRESPONDENCE|DECEMBER 19, 2020<\/p>\n\n\n\n
St\u00e9phane Gaudry and colleagues1<\/a><\/sup>\u00a0found 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<\/a><\/sup>\u00a0shows 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<\/a>) category ,2<\/a><\/sup>\u00a0or acute kidney injury stage, and data are missing on residual diuresis. Additionally, details on drug treatment in the Article,1<\/a><\/sup>\u00a0such 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.<\/p>\n\n\n\n St\u00e9phane Gaudry\u53ca\u5176\u540c\u4e8b\u53d1\u73b0\uff0c\u4e0e\u5ef6\u8fdf\u5f00\u59cb\u80be\u810f\u66ff\u4ee3\u6cbb\u7597(RRT)\u76f8\u6bd4\uff0c\u53d1\u751f\u6025\u6027\u80be\u635f\u4f24\u7684\u5371\u91cd\u75c5\u60a3\u8005\u65e9\u671f\u63a5\u53d7RRT\u5e76\u4e0d\u5f71\u54cd\u751f\u5b58\u7387\u3002\u8fd9\u4e2ameta\u5206\u6790\u7684\u4e3b\u8981\u5c40\u9650\u6027\u4e4b\u4e00\u662f\u5173\u4e8eRRT\u7684\u65f6\u673a\u548c\u5904\u65b9\u7684\u4e34\u5e8a\u51b3\u7b56\u3002\u800c\u4e14\uff0c\u7eb3\u5165\u7684\u7814\u7a76\u4e2d\u8981\u6c42\u60a3\u8005\u6536\u5165ICU\u4f7f\u5f97\u591a\u6570\u6025\u6027\u80be\u635f\u4f24\u60a3\u8005\u6709\u673a\u4f1a\u63a5\u53d7\u5176\u4ed6\u6cbb\u7597\u63aa\u65bd\u5982\u673a\u68b0\u901a\u6c14\uff0c\u800c\u8fd9\u4e9b\u6cbb\u7597\u63aa\u65bd\u5728\u5185\u79d1\u6216\u80be\u810f\u5185\u79d1\u75c5\u623f\u5e76\u4e0d\u5177\u5907\u3002\u6587\u7ae0\u53d1\u73b0\uff0c\u63a5\u53d7\u5ef6\u8fdf\u6216\u65e9\u671fRRT\u7684\u60a3\u800528\u5929\u75c5\u6b7b\u7387\u5e76\u65e0\u5dee\u5f02\u3002\u7136\u800c\uff0c\u7eb3\u5165\u76848\u9879\u7814\u7a76\u4e2d\u4ec5\u67092\u9879\u662f\u5728\u80be\u810f\u5185\u79d1\u8fdb\u884c\u7684\u3002\u8fd9\u4e9b\u7814\u7a76\u5e76\u6ca1\u6709\u62a5\u544a\u6162\u6027\u80be\u75c5\u53caKDIGO\u5206\u7ea7\u7684\u60a3\u8005\u6570\uff0c\u4e5f\u6ca1\u6709\u62a5\u544a\u6025\u6027\u80be\u635f\u4f24\u7684\u5206\u7ea7\uff0c\u800c\u4e14\u7f3a\u4e4f\u6b8b\u4f59\u80be\u529f\u80fd\u7684\u6570\u636e\u3002\u53e6\u5916\uff0c\u6587\u7ae0\u4e2d\u4e5f\u6ca1\u6709\u62a5\u544a\u836f\u7269\u6cbb\u7597\u7684\u7ec6\u8282\uff0c\u59821205\u540d\u8113\u6bd2\u75c7\u60a3\u8005\u4e2d525\u540d\u63a5\u53d7\u4e86\u6297\u751f\u7d20\u6cbb\u7597\u3002\u7eb3\u5165\u7684\u7814\u7a76\u4e5f\u6ca1\u6709\u62a5\u544a\u8fd9\u4e9b\u4e34\u5e8a\u8d44\u6599\uff0c\u4ece\u800c\u589e\u52a0\u4e86meta\u5206\u6790\u7684\u5c40\u9650\u6027\u3002<\/p>\n\n\n\n In our opinion, the message that RRT in patients with acute kidney injury \u201ccan be safely postponed\u201d1<\/a><\/sup>\u00a0should 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.<\/p>\n\n\n\n \u4ece\u6211\u4eec\u770b\u6765\uff0c\u6709\u5173\u6025\u6027\u80be\u635f\u4f24\u60a3\u8005\u5ef6\u8fdfRRT\u662f\u5b89\u5168\u7684\uff0c\u8fd9\u4e00\u7ed3\u8bba\u5e94\u5f53\u8c28\u614e\u5bf9\u5f85\u3002\u4e0e\u6536\u5165ICU\u7684\u6025\u6027\u80be\u635f\u4f24\u60a3\u8005\u76f8\u6bd4\uff0c\u5bf9\u4e8e\u6536\u5165\u5185\u79d1\u75c5\u623f\u7684\u6025\u6027\u80be\u635f\u4f24\u60a3\u8005\uff0c\u5f97\u51fa\u8fd9\u4e00\u7ed3\u8bba\u9700\u8981\u66f4\u52a0\u8c28\u614e\u3002<\/p>\n\n\n\n CORRESPONDENCE|DECEMBER 19, 2020<\/p>\n\n\n\n St\u00e9phane Gaudry and colleagues1<\/a><\/sup>\u00a0compared 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.2<\/a>,\u00a03<\/a><\/sup>\u00a0Gaudry and colleagues1<\/a><\/sup>\u00a0rated 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.<\/p>\n\n\n\n St\u00e9phane Gaudry\u53ca\u5176\u540c\u4e8b\u5bf9\u4e25\u91cd\u6025\u6027\u80be\u635f\u4f24\u60a3\u8005\u5ef6\u8fdf\u4e0e\u65e9\u671f\u5f00\u59cb\u80be\u810f\u66ff\u4ee3\u6cbb\u7597(RRT)\u8fdb\u884c\u4e86\u6bd4\u8f83\u3002\u8fd9\u4e2ameta\u5206\u6790\u7684\u4f18\u70b9\u4e4b\u4e00\u5728\u4e8e\u4f7f\u7528GRADE\u8bc4\u4ef7\u8bc1\u636e\u7684\u786e\u5b9a\u6027\u3002Gaudry\u53ca\u5176\u540c\u4e8b\u5c0628\u5929\u75c5\u6b7b\u7387\uff0c60\u5929\u75c5\u6b7b\u7387\u53ca\u4f4f\u9662\u75c5\u6b7b\u7387\u4f5c\u4e3a\u53cd\u6620\u60a3\u8005\u9884\u540e\u7684\u9ad8\u786e\u5b9a\u6027\u8bc1\u636e\uff0c\u4ece\u800c\u5f97\u5230\u7ed3\u8bba\u5373\u5bf9\u4e8e\u6025\u6027\u80be\u635f\u4f24\u60a3\u8005\uff0c\u65e9\u671f\u6216\u5ef6\u8fdf\u5f00\u59cbRRT\u65f6\u75c5\u6b7b\u7387\u5e76\u65e0\u663e\u8457\u5dee\u5f02\u3002\u7136\u800c\uff0c\u5f53\u6839\u636e\u7edd\u5bf9\u6548\u5e94\u8fdb\u884c\u7ed3\u679c\u89e3\u8bfb\u65f6\uff0c\u8fd9\u4e00\u7ed3\u8bba\u53ef\u80fd\u6709\u6240\u6539\u53d8\u3002<\/p>\n\n\n\n Gaudry and colleagues1<\/a><\/sup>\u00a0considered 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<\/a>). 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.<\/p>\n\n\n\n Gaudry\u53ca\u5176\u540c\u4e8b\u8ba4\u4e3a\uff0c\u76f8\u5bf9\u6548\u5e94\u7684\u53ef\u4fe1\u533a\u95f4\u5f88\u7a84\uff0c\u5373\u5176\u4e0a\u9650\u548c\u4e0b\u9650\u90fd\u4e0e0\u6548\u5e94\uff08\u76f8\u5bf9\u6548\u5e94\uff09\u975e\u5e38\u63a5\u8fd1\uff0c\u56e0\u800c\u5e76\u6ca1\u6709\u56e0\u4e3a\u7f3a\u4e4f\u7cbe\u786e\u6027\u4e0b\u8c03\u8bc1\u636e\u786e\u5b9a\u6027\u7b49\u7ea7\u3002\u7136\u800c\uff0c\u7edd\u5bf9\u6548\u5e94\u53ef\u80fd\u63d0\u793a\u4e0d\u540c\u7684\u7ed3\u8bba\u3002\u5ef6\u8fdf\u4e0e\u65e9\u671fRRT\u7ec4\u95f428\u5929\u75c5\u6b7b\u7387\u7684\u7edd\u5bf9\u5dee\u5f02\u5728\u6bcf1000\u4f8b\u60a3\u8005\u5c11\u6b7b\u4ea138\u4f8b\u5230\u591a\u6b7b\u4ea156\u4f8b\u4e4b\u95f4\u3002\u5176\u4e0b\u9650\u63d0\u793a\u5ef6\u8fdfRRT\u6bd4\u65e9\u671fRRT\u6709\u663e\u8457\u83b7\u76ca\uff0c\u800c\u4e0a\u9650\u63d0\u793a\u5b8c\u5168\u76f8\u53cd\u7684\u7ed3\u679c\u300260\u5929\u75c5\u6b7b\u7387\u4e0e\u4f4f\u9662\u75c5\u6b7b\u7387\u4e5f\u5f97\u5230\u76f8\u4f3c\u7ed3\u679c\u3002\u901a\u8fc7\u4e86\u89e3\u7edd\u5bf9\u6548\u5e94\uff0c\u6211\u4eec\u53ef\u80fd\u5c06\u4e0a\u8ff03\u4e2a\u75c5\u6b7b\u7387\u7ed3\u5c40\u7684\u8bc1\u636e\u786e\u5b9a\u6027\u7ea7\u522b\u4ece\u9ad8\u4e0b\u8c03\u5230\u4e2d\u5ea6\u3002\u56e0\u800c\uff0c\u6211\u4eec\u5e76\u4e0d\u786e\u5b9a\u5ef6\u8fdfRRT\u8f83\u65e9\u671fRRT\u7684\u771f\u6b63\u6548\u5e94\u662f\u5426\u5177\u6709\u91cd\u8981\u7684\u4e34\u5e8a\u5dee\u5f02\u3002<\/p>\n\n\n\n To conclude, a conservative conclusion might be more appropriate to this study\u2014the 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<\/a><\/sup><\/p>\n\n\n\n \u603b\u4e4b\uff0c\u8fd9\u4e2a\u7814\u7a76\u5e94\u5f53\u5f97\u5230\u66f4\u52a0\u4fdd\u5b88\u7684\u7ed3\u8bba\uff0c\u5373\u5f00\u59cbRRT\u7684\u65f6\u673a\u53ef\u80fd\u4e0d\u5f71\u54cd\u4e25\u91cd\u6025\u6027\u80be\u635f\u4f24\u7684\u5371\u91cd\u75c5\u60a3\u8005\u7684\u751f\u5b58\u7387\u3002\u8003\u8651\u7edd\u5bf9\u6548\u5e94\u53ef\u80fd\u6709\u52a9\u4e8e\u89e3\u8bfb\u8fd9\u4e00\u7814\u7a76\u7684\u7ed3\u679c\u3002<\/p>\n","protected":false},"excerpt":{"rendered":" CORRESPONDENCE|DECEMBER 19, 2020 Renal replacement ther […]<\/p>\n","protected":false},"author":3,"featured_media":0,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":[],"categories":[24,23],"tags":[],"_links":{"self":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/19660"}],"collection":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts"}],"about":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/types\/post"}],"author":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/users\/3"}],"replies":[{"embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcomments&post=19660"}],"version-history":[{"count":3,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/19660\/revisions"}],"predecessor-version":[{"id":19666,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/19660\/revisions\/19666"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=19660"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=19660"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=19660"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}Renal replacement therapy in acute kidney injury<\/h1>\n\n\n\n
Zhenxing Lu, Beijing Yan, Kehu Yang, et al<\/h3>\n\n\n\n
Lancet 2020; 396: 1974-1975 DOI:https:\/\/doi.org\/10.1016\/S0140-6736(20)32405-3<\/a><\/h3>\n\n\n\n