法国巴黎大学Didier Dreyfuss团队比较了两种延迟肾替代治疗策略对严重急性肾损伤（AKIKI2）患者的影响。2021年4月3日，《柳叶刀》杂志发表了该成果。

对于严重急性肾损伤且无严重并发症的危重患者，延迟一段时间的肾脏替代治疗（RRT）是安全的，并允许优化医疗设备的使用。在无风险的情况下，RRT可延长的期限仍存在重大不确定性。

研究组在法国的39个重症监护病房进行了一项非盲、多中心、前瞻性、开放标签、随机、对照试验。研究组对严重急性肾损伤的危重患者进行监测，直到他们少尿超过72小时或血尿素氮浓度高于112 mg/dL。然后将患者按1：1随机分为两组，一组是在随机分组后立即开始RRT（延迟策略），另一组是更延迟的策略，即当出现强制性适应症（明显的高钾血症或代谢性酸中毒或肺水肿）或血尿素氮浓度达到140 mg/dL时才开始RRT。主要结局是随机分组至第28天间的存活天数和无RRT的天数。

2018年5月7日至2019年10月11日，在5336名患者中，共有278名接受随机分组；其中延迟策略组137名，更延迟策略组141名。两组之间可能与急性肾损伤或RRT相关的并发症数量相似。延迟策略组中位无RRT天数为12天，更延迟策略组为10天，差异不显著。在多变量分析中，更延迟策略组与延迟策略组相比，60天死亡的风险比为1.65，差异显著。两组之间可能与急性肾损伤或肾脏替代治疗相关的并发症数量没有差异。

研究结果表明，对于少尿超过72小时或血尿素氮浓度高于112 mg/dL，且没有需要立即进行RRT的严重并发症的严重急性肾损伤患者，延迟RRT启动时间较长并没有带来额外的好处，而且与潜在的危害相关。

附：英文原文

Title: Comparison of two delayed strategies for renal replacement therapy initiation for severe acute kidney injury (AKIKI 2): a multicentre, open-label, randomised, controlled trial

Author: Stéphane Gaudry, David Hajage, Laurent Martin-Lefevre, Sad Lebbah, Guillaume Louis, Sébastien Moschietto, Dimitri Titeca-Beauport, Béatrice La Combe, Bertrand Pons, Nicolas de Prost, Sébastien Besset, Alain Combes, Adrien Robine, Marion Beuzelin, Julio Badie, Guillaume Chevrel, Julien Bohé, Elisabeth Coupez, Nicolas Chudeau, Saber Barbar, Christophe Vinsonneau, Jean-Marie Forel, Didier Thevenin, Eric Boulet, Karim Lakhal, Nadia Aissaoui, Steven Grange, Marc Leone, Guillaume Lacave, Saad Nseir, Florent Poirson, Julien Mayaux, Karim Asehnoune, Guillaume Geri, Kada Klouche, Guillaume Thiery, Laurent Argaud, Bertrand Rozec, Cyril Cadoz, Pascal Andreu, Jean Reignier, Jean-Damien Ricard, Jean-Pierre Quenot, Didier Dreyfuss

Issue&Volume: 2021/04/03

Abstract:

Background

Delaying renal replacement therapy (RRT) for some time in critically ill patients with severe acute kidney injury and no severe complication is safe and allows optimisation of the use of medical devices. Major uncertainty remains concerning the duration for which RRT can be postponed without risk. Our aim was to test the hypothesis that a more-delayed initiation strategy would result in more RRT-free days, compared with a delayed strategy.

Methods

This was an unmasked, multicentre, prospective, open-label, randomised, controlled trial done in 39 intensive care units in France. We monitored critically ill patients with severe acute kidney injury (defined as Kidney Disease: Improving Global Outcomes stage 3) until they had oliguria for more than 72 h or a blood urea nitrogen concentration higher than 112 mg/dL. Patients were then randomly assigned (1:1) to either a strategy (delayed strategy) in which RRT was started just after randomisation or to a more-delayed strategy. With the more-delayed strategy, RRT initiation was postponed until mandatory indication (noticeable hyperkalaemia or metabolic acidosis or pulmonary oedema) or until blood urea nitrogen concentration reached 140 mg/dL. The primary outcome was the number of days alive and free of RRT between randomisation and day 28 and was done in the intention-to-treat population. The study is registered with ClinicalTrial.gov, NCT03396757 and is completed.

Findings

Between May 7, 2018, and Oct 11, 2019, of 5336 patients assessed, 278 patients underwent randomisation; 137 were assigned to the delayed strategy and 141 to the more-delayed strategy. The number of complications potentially related to acute kidney injury or to RRT were similar between groups. The median number of RRT-free days was 12 days (IQR 0–25) in the delayed strategy and 10 days (IQR 0–24) in the more-delayed strategy (p=0·93). In a multivariable analysis, the hazard ratio for death at 60 days was 1·65 (95% CI 1·09–2·50, p=0·018) with the more-delayed versus the delayed strategy. The number of complications potentially related to acute kidney injury or renal replacement therapy did not differ between groups.

Interpretation

In severe acute kidney injury patients with oliguria for more than 72 h or blood urea nitrogen concentration higher than 112 mg/dL and no severe complication that would mandate immediate RRT, longer postponing of RRT initiation did not confer additional benefit and was associated with potential harm.

DOI: 10.1016/S0140-6736(21)00350-0

Source: https://www.thelancet.com/journals/lancet/article/PIIS0140-6736(21)00350-0/fulltext