CORRESPONDENCE<\/p>\n\n\n\n
We disagree with Vincenzo Sepe and colleagues' comment about the timing and prescription of renal replacement therapy (RRT). In the randomised controlled trials included in our systematic review and individual patient data meta-analysis,1<\/a><\/sup>\u00a0the protocol was precise; it mandated starting RRT as soon as Kidney Disease: Improving Global Outcomes acute kidney injury stage 2 or 3 was present in the early strategy, and it had stringent criteria for initiating RRT in the delayed strategy, such as severe hyperkalaemia or acidosis, among others. Obviously, clinicians had some degree of freedom in the interpretation of such criteria, which is scientifically and ethically desirable. If we follow Sepe and colleagues' reasoning, all randomised controlled trials in the field would be subject to the same criticism, including STARRT-AKI,2<\/a><\/sup>\u00a0which is the largest trial to date.<\/p>\n\n\n\n \u6211\u4eec\u4e0d\u540c\u610fVincenzo Sepe\u53ca\u5176\u540c\u4e8b\u6709\u5173\u80be\u810f\u66ff\u4ee3\u6cbb\u7597(RRT)\u65f6\u673a\u53ca\u5904\u65b9\u7684\u8bc4\u8bba\u3002\u5728\u6211\u4eec\u7684\u7cfb\u7edf\u56de\u987e\u4ee5\u53ca\u4e2a\u4f53\u75c5\u4f8b\u6570\u636emeta\u5206\u6790\u4e2d\uff0c\u7eb3\u5165\u7684\u968f\u673a\u5bf9\u7167\u8bd5\u9a8c\u7684\u8bd5\u9a8c\u65b9\u6848\u975e\u5e38\u8be6\u5c3d\uff1b\u65e9\u671f\u7b56\u7565\u7ec4\u8981\u6c42\u6025\u6027\u80be\u635f\u4f24\u7684KDIGO\u5206\u7ea72\u62163\u7ea7\u65f6\u5c3d\u5feb\u5f00\u59cbRRT\uff0c\u5ef6\u8fdf\u7b56\u7565\u7ec4\u5f00\u59cbRRT\u4e5f\u6709\u4e25\u683c\u6807\u51c6\uff0c\u5982\u4e25\u91cd\u9ad8\u94be\u8840\u75c7\u6216\u9178\u4e2d\u6bd2\u3002\u5f88\u660e\u663e\uff0c\u4e34\u5e8a\u533b\u751f\u5728\u89e3\u8bfb\u8fd9\u4e9b\u6807\u51c6\u65f6\u5177\u6709\u4e00\u5b9a\u7684\u81ea\u7531\u5ea6\uff0c\u4ece\u79d1\u5b66\u548c\u4f26\u7406\u89d2\u5ea6\u90fd\u662f\u5141\u8bb8\u7684\u3002\u5982\u679c\u6211\u4eec\u9075\u4eceSepe\u53ca\u5176\u540c\u4e8b\u7684\u63a8\u7406\uff0c\u540c\u6837\u7684\u6279\u8bc4\u610f\u89c1\u9002\u7528\u4e8e\u8fd9\u4e00\u9886\u57df\u4e2d\u6240\u6709\u7684\u968f\u673a\u5bf9\u7167\u8bd5\u9a8c\uff0c\u5305\u62ec\u8fc4\u4eca\u4e3a\u6b62\u6700\u5927\u6837\u672c\u7684\u4e34\u5e8a\u8bd5\u9a8c\u5373STARRT-AKI\u7814\u7a76\u3002<\/p>\n\n\n\n With regards to Sepe and colleagues' second comment, indeed, most patients with severe acute kidney injury have multiple system organ failures and require care intensive care.3<\/a><\/sup>\u00a0The COVID-19 pandemic is a tragic example of this situation. Do they consider that a simple renal unit or an internal medicine ward would be able to save the lives of patients with severe acute respiratory distress syndrome, septic shock, and acute kidney injury? Intensive care units (ICUs) probably do not care for the same patients as Sepe and colleagues care for, and we would be interested in having more data from their own experience. We believe that not taking care of patients who have multiple system organ failure in an ICU is not safe in a high-outcome country with modern care. Interestingly, in the only study done in a country that could not offer ICU beds for all patients, results were in favour of a delayed RRT strategy.4<\/a><\/sup><\/p>\n\n\n\n \u6709\u5173Sepe\u53ca\u5176\u540c\u4e8b\u7684\u7b2c\u4e8c\u4e2a\u8bc4\u8bba\uff0c\u4e8b\u5b9e\u4e0a\uff0c\u591a\u6570\u4e25\u91cd\u6025\u6027\u80be\u635f\u4f24\u60a3\u8005\u540c\u65f6\u6709\u591a\u5668\u5b98\u529f\u80fd\u8870\u7aed\uff0c\u56e0\u800c\u9700\u8981\u6536\u5165ICU\u3002COVID-19\u75ab\u60c5\u5c31\u662f\u8fd9\u79cd\u60c5\u51b5\u7684\u4e00\u4e2a\u5178\u578b\u4f8b\u8bc1\u3002\u4ed6\u4eec\u662f\u5426\u8ba4\u4e3a\u5355\u7eaf\u80be\u810f\u5185\u79d1\u75c5\u623f\u6216\u5185\u79d1\u75c5\u623f\u5c31\u8db3\u4ee5\u633d\u6551\u91cd\u5ea6ARDS\u3001\u611f\u67d3\u6027\u4f11\u514b\u548c\u6025\u6027\u80be\u635f\u4f24\u60a3\u8005\u7684\u751f\u547d\u3002ICU\u6536\u6cbb\u7684\u60a3\u8005\u53ef\u80fd\u4e0eSepe\u53ca\u5176\u540c\u4e8b\u6cbb\u7597\u7684\u60a3\u8005\u4e0d\u540c\uff0c\u6211\u4eec\u6709\u5174\u8da3\u4e86\u89e3\u6839\u636e\u4ed6\u4eec\u81ea\u5df1\u7ecf\u9a8c\u7684\u6240\u603b\u7ed3\u7684\u6570\u636e\u3002\u6211\u4eec\u76f8\u4fe1\uff0c\u5728\u9ad8\u6536\u5165\u56fd\u5bb6\u4e2d\uff0c\u5c06\u591a\u5668\u5b98\u529f\u80fd\u8870\u7aed\u60a3\u8005\u653e\u5728ICU\u4e4b\u5916\u63a5\u53d7\u6cbb\u7597\u5e76\u4e0d\u5b89\u5168\u3002\u6709\u8da3\u7684\u662f\uff0c\u5728\u65e0\u6cd5\u4e3a\u6240\u6709\u60a3\u8005\u63d0\u4f9bICU\u5e8a\u4f4d\u7684\u56fd\u5bb6\u6240\u505a\u7684\u552f\u4e00\u7814\u7a76\u652f\u6301\u5ef6\u8fdfRRT\u7684\u7b56\u7565\u3002<\/p>\n\n\n\n We also do not agree with the contention by Zhenxing Lu and colleagues that considering absolute effect would modify our conclusion. We have already reported the results for mortality at day 28, our primary endpoint in terms of absolute risk difference.1<\/a><\/sup> Regardless of the endpoint definition (ie, mortality at day 28, day 60, hospital mortality), the absolute risk difference is close to 0, and the 95% CI is narrow (0\u00b701 [95% CI \u22120\u00b704 to 0\u00b706] for mortality at day 28; 0\u00b700 [\u20130\u00b705 to 0\u00b705] for mortality at day 60; \u22120\u00b701 [\u20130\u00b706 to 0\u00b703] for hospital mortality). Our meta-analysis provides a fairly accurate estimate of the absolute difference in mortality between the groups of patients receiving delayed and early RRT. Zhenxing Lu and colleagues express these differences in number of deaths per 1000 patients, which might exaggerate the impression of imprecision (it would be even worse if expressed by millions of patients), yet this does not change our results. We wonder what degree of precision would have been considered sufficient to Zhenxing Lu and colleagues; however, we want to highlight that many non-inferiority trials in ICUs admit a non-inferiority margin for mortality equal to or higher than 0\u00b705.5<\/a><\/sup><\/p>\n\n\n\n \u6211\u4eec\u4e5f\u4e0d\u540c\u610fZhenxing Lu\u53ca\u5176\u540c\u4e8b\u7684\u610f\u89c1\uff0c\u4ed6\u4eec\u8ba4\u4e3a\u7edd\u5bf9\u6548\u5e94\u53ef\u80fd\u6539\u53d8\u6211\u4eec\u7684\u7ed3\u8bba\u3002\u6211\u4eec\u62a5\u544a\u4e86\u4e3b\u8981\u7814\u7a76\u7ec8\u70b9\u537328\u5929\u75c5\u6b7b\u7387\u7684\u7edd\u5bf9\u6548\u5e94\u3002\u65e0\u8bba\u4e3b\u8981\u7814\u7a76\u7ec8\u70b9\u7684\u5b9a\u4e49\u5982\u4f55\uff0828\u5929\uff0c60\u5929\u53ca\u4f4f\u9662\u75c5\u6b7b\u7387\uff09\uff0c\u5176\u7edd\u5bf9\u98ce\u9669\u5dee\u5f02\u5747\u63a5\u8fd10\uff0c95% CI\u8303\u56f4\u5f88\u7a84\uff0828\u5929\u75c5\u6b7b\u73870\u00b701 [95% CI \u22120\u00b704 to 0\u00b706]\uff1b60\u5929\u75c5\u6b7b\u7387 0\u00b700 [\u20130\u00b705 to 0\u00b705]\uff1b\u4f4f\u9662\u75c5\u6b7b\u7387\u22120\u00b701 [\u20130\u00b706 to 0\u00b703]\uff09\u3002\u6211\u4eec\u7684meta\u5206\u6790\u5bf9\u4e8e\u63a5\u53d7\u5ef6\u8fdf\u548c\u65e9\u671fRRT\u60a3\u8005\u75c5\u6b7b\u7387\u7684\u7edd\u5bf9\u5dee\u5f02\u63d0\u4f9b\u4e86\u8f83\u4e3a\u51c6\u786e\u7684\u8bc4\u4ef7\u3002Zhenxing Lu\u53ca\u5176\u540c\u4e8b\u5c06\u8fd9\u4e00\u5dee\u5f02\u8868\u793a\u4e3a\u6bcf1000\u4f8b\u60a3\u8005\u7684\u6b7b\u4ea1\u4eba\u6570\uff0c\u8fd9\u53ef\u80fd\u589e\u52a0\u5bf9\u4e8e\u7ed3\u679c\u4e0d\u51c6\u786e\u7684\u5370\u8c61\uff08\u5982\u679c\u5c06\u7ed3\u679c\u8868\u793a\u4e3a\u6bcf1000000\u4f8b\u60a3\u8005\u5c06\u4f1a\u66f4\u7cdf\u7cd5\uff09\uff0c\u7136\u800c\u8fd9\u5e76\u4e0d\u6539\u53d8\u6211\u4eec\u7684\u7ed3\u679c\u3002\u6211\u4eec\u60f3\u77e5\u9053Zhenxing Lu\u53ca\u5176\u540c\u4e8b\u8ba4\u4e3a\u7cbe\u786e\u5ea6\u8fbe\u5230\u4f55\u79cd\u7a0b\u5ea6\u624d\u8db3\u591f\uff1b\u7136\u800c\uff0c\u6211\u4eec\u5e0c\u671b\u6307\u51fa\u7684\u662f\uff0c\u5f88\u591aICU\u7684\u975e\u52a3\u6548\u8bd5\u9a8c\u5c06\u75c5\u6b7b\u7387\u7684\u975e\u52a3\u6548\u754c\u503c\u7b49\u4e8e\u6216\u9ad8\u4e8e0.05\u3002<\/p>\n","protected":false},"excerpt":{"rendered":" CORRESPONDENCE Renal replacement therapy in acute kidne […]<\/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\/19662"}],"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=19662"}],"version-history":[{"count":3,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/19662\/revisions"}],"predecessor-version":[{"id":19667,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=\/wp\/v2\/posts\/19662\/revisions\/19667"}],"wp:attachment":[{"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fmedia&parent=19662"}],"wp:term":[{"taxonomy":"category","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Fcategories&post=19662"},{"taxonomy":"post_tag","embeddable":true,"href":"https:\/\/csccm.org.cn\/index.php?rest_route=%2Fwp%2Fv2%2Ftags&post=19662"}],"curies":[{"name":"wp","href":"https:\/\/api.w.org\/{rel}","templated":true}]}}