Can early initiation of continuous renal replacement therapy improve patient survival with septic acute kidney injury when enrolled in early goal-directed therapy?

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• 作者：Hyung Jung Oh^a ; Min Hyung Kim^b ; Jin Young Ahn^b ; Nam Su Ku^b ; ^{smileboy9@yuhs.ac" class="auth_mail" title="E-mail the corresponding author} ; Jung Tak Park^a ; Sang Hoon Han^b ; Jun Yong Choi^b ; Seung Hyeok Han^a ; Tae-Hyun Yoo^a ; Young Goo Song^b ; Shin-Wook Kang^a ; June Myung Kim^b
• 关键词：Sepsis ; EGDT ; AKI ; Early CRRT ; 28-Day mortality
• 刊名：Journal of Critical Care
• 出版年：2016
• 出版时间：October 2016
• 年：2016
• 卷：35
• 期：Complete
• 页码：51-56
• 全文大小：386 K

文摘

The purpose of our study was to investigate the timing of continuous renal replacement therapy (CRRT) application, based on the interval between the start of early goal-directed therapy (EGDT) and CRRT initiation, to ascertain whether the timing was an independent predictor of mortality in patients with septic acute kidney injury (AKI).

Materials and methods

An observational retrospective cohort study was conducted of 60 patients (> 18 years old) who had been admitted to the emergency department and received resuscitation according to the standard EGDT algorithm for severe sepsis and septic shock, and who were treated with CRRT due to septic AKI, between June 2008 and February 2013 at a tertiary hospital in Seoul, Korea. The patients were divided into 2 groups based on the median interval between the start of EGDT and the commencement of CRRT. The main outcome was 28-day all-cause mortality, and a multivariate Cox analysis for mortality was used to evaluate the independent impact of the early CRRT treatment.

Results

The mean patient age was 66.3 years, and 52 (86.7%) were male. The most common comorbid disease was diabetes mellitus (35.0%) followed by malignancy (26.7%). The median interval between the start of EGDT and commencement of CRRT was 26.4 hours. During the study period, 28-day mortality was 43.3% (26 of 60 patients). The 28-day all-cause mortality rate was significantly higher in the late CRRT group than in the early CRRT group (56.7 vs 30.0%, P= .037). Furthermore, the higher mortality risk in the late group remained significant even after adjusting for diabetes mellitus, liver failure, and Acute Physiology and Chronic Health Evaluation II scores (hazard ratio, 2.461; 95% confidence interval, 1.044-5.800; P= .026).

Conclusion

Early initiation of CRRT may be of benefit. Given the complex nature of this intervention and the ongoing controversy regarding early vs late initiation of therapy in acute and chronic situations, it is vital to develop accurate clinical trials to find definitive answers.