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cover of episode SCCM Pod-534: AKI: Clinical Evidence to Optimize Patient Outcomes

SCCM Pod-534: AKI: Clinical Evidence to Optimize Patient Outcomes

2025/3/21
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Jay Koyner
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Ron Wald
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Ron Wald: 我在肾脏病学研究中，一直对ICU中急性肾损伤（AKI）患者的肾脏替代疗法选择很感兴趣。传统上，我们对血液动力学稳定的患者使用CRRT，对其他患者使用IHD。虽然临床试验表明CRRT没有明显的死亡率益处，但我认为CRRT对合适的患者仍然很重要，并且希望探索CRRT相较于其他肾脏替代疗法的其他益处。我的研究利用START-AKI试验的数据，比较了CRRT和IHD的疗效。由于并非随机对照试验，我们使用了倾向性评分匹配方法来平衡两组患者的基线特征。研究结果显示，CRRT启动与90天内死亡或透析依赖的复合终点发生率较低，这主要是因为透析依赖率降低。CRRT似乎与更高的肾脏存活率相关，尤其是在患者存活到90天的情况下。虽然我们的研究提示CRRT可能降低透析依赖风险，但我仍然谨慎地解释结果，并强调CRRT并非对所有患者都是最佳选择。我认为患者的基础疾病，而非CRRT或IHD的选择，才是决定患者预后的主要因素。虽然CRRT可能无法提高ICU中的生存率，但它可能影响肾脏的缺血负荷，并减少慢性透析依赖的风险。减少慢性透析依赖对患者生活质量有重要意义，因为慢性透析依赖与更高的死亡风险相关。CRRT是去除大量液体积聚的有效方法，不应仅限于血液动力学不稳定的患者。 Jay Koyner: 与Ron类似，我观察到一些患者在间歇性血液透析（IHD）上的疗效不如持续性肾脏替代疗法（CRRT）。虽然有一些明确的CRRT指征，但仍存在很多不确定性，我们需要确定CRRT的实际益处是否值得其高昂的成本和人力投入。我的研究使用了美国Premier Health数据库，分析了接受透析治疗的AKI患者的90天预后，并使用逆概率治疗加权法来平衡CRRT和IHD组的患者特征。研究结果显示，CRRT作为首选治疗方式与更高的肾脏恢复率相关，即使在考虑了患者特征差异后也是如此。虽然我们的研究并非随机对照试验，但越来越多的证据表明CRRT可能对某些患者有益，特别是在那些血液动力学不稳定的患者中。虽然CRRT可能提高肾脏恢复率，但我们应该谨慎乐观，并认识到CRRT并非万能的。我认为CRRT可能不仅对肾脏有益，还可能减少对患者心血管系统的负荷。

Deep Dive

Chapters
This chapter explores the research on renal replacement therapy (RRT) choices for ICU patients with acute kidney injury (AKI), focusing on continuous renal replacement therapy (CRRT) versus intermittent hemodialysis (IHD). Dr. Wald's study, a secondary analysis of the START-AKI trial, and Dr. Koiner's study using the Premier Health database, both investigated the association between initial RRT modality and outcomes like mortality and dialysis dependence.
  • CRRT initiation was associated with lower dialysis dependence at 90 days.
  • No clear mortality benefit of CRT was found.
  • Propensity score matching was used to balance baseline characteristics between CRT and IHD groups.

Shownotes Transcript

What form of renal replacement therapy should clinicians use for patients in the intensive care unit (ICU)? New research has connected the renal replacement therapy choice with mortality end points and renal replacement therapy dependency in patients with acute kidney injury. In this podcast episode, experts discuss their research in this area.

Ron Wald, MDCM, MHP, professor of medicine at the University of Toronto, discusses his article, “Initiation of Continuous Renal Replacement Therapy Versus Intermittent Hemodialysis in Critically Ill Patients With Severe Acute Kidney Injury: A Secondary Analysis of STARRT-AKI Trial,”) published in the November 2023 issue of Intensive Care Medicine.

Jay Koyner, MD, professor of medicine and director of the nephrology intensive care unit at the University of Chicago, discuss his article, “Initial Renal Replacement Therapy (RRT) Modality Associates With 90-Day Postdischarge RRT Dependence in Critically Ill AKI Survivors,”) published in the August 2024 issue of Journal of Critical Care.

This podcast is sponsored by Vantive U.S. Healthcare). Vantive supports true patient-focused treatments with industry-leading CRRT technology and is a partner dedicated to optimizing your clinical success in treating patients with acute kidney injury. Our commitment to you starts with education and provides complete support every step of the way. Visit us at vantive.com).