连续性肾脏替代治疗剂量对急性肾衰竭患者预后影响的荟萃分析

Meta-analysis of impact of continuous renal replacement therapy dose on outcome of acute renal failure patients

目的 通过荟萃分析评价连续性肾脏替代治疗（CRRT）剂量对急性肾衰竭（ARF）患者预后的影响.方法 制定原始文献的纳入标准和检索策略,在Medline、EMBASE及Cochrane图书馆内进行相关的检索.比较标准剂量和低剂量CRRT对ARF患者预后影响的随机对照试验（RCT）纳入分析.应用随机或固定效应模型处理预后指标的相对危险度（RR）.结果 6项研究符合纳入标准.与低剂量比较,标准剂量CRRT未能降低病死率（RR0.87,95%CI 0.70～1.07,P=0.19）和联合终点事件（死亡和依赖透析）的发生率（RR0.87,95%CI 0.69～1.09,P=0.21）,但有增加依赖透析率的趋势（RR 1.43,95%CI 0.94～2.18,P=0.09）.由于研究间存在异质性,亚组分析显示,实际治疗剂量达标（标准剂量＞35 ml·kg^-1-min^-1）、治疗模式以连续性静脉-静脉血液滤过（CVVH）为主（置换液量大于透析液量）、非脓毒症为ARF主要原因（脓毒血症发病率＜50%）的研究中,经标准剂量CRRT后病死率显著下降（P＜0.01）.结论 尽管标准剂量CRRT未能降低ARF患者的病死率、依赖透析率和联合终点事件的发生率,但可改善实际治疗剂量达标、治疗模式以CVVH为主及非脓毒症ARF患者的存活率.

Objective To assess the effect of continuous renal-replacement therapy （CRRT） dose on the outcome of acute renal failure （ARF） patients with meta-analysis of randomized controlled trials （RCTs）. Methods Studies were identified by systematic search of peer-reviewed publications in Medline, EMBASE and Cochrane library database through June 2010. All the RCTs that compared the incidence of clinical outcome such as mortality, need for chronic dialysis between standard and low dose CRRT were eligible. The pooled relative risk （RR） for clinical outcome was compiled using a random-effects model. Heterogeneity was evaluated by means of subgroup and sensitivity analysis. Results Six eligible studies were identified. By meta-analysis, standard dose CRRT was associated with non-significant 13% mortality risk reduction （RR 0.87, 95%CI 0.70-1.07, P=0.19）and 13% composite outcome risk reduction of chronic dialysis dependence and mortality （RR 0.87, 95%CI 0.69-1.09, P=0.21）, but the trend toward increased chronic dialysis dependence risk among survivors （RR 1.43, 95%CI 0.94-2.18, P=0.09）. The overall test for heterogeneity among cohort studies was significant （P=0.001, I2=76.2%）. The risk of mortality was modality was significantly lower in some studies of which delivered dose was moer than 35 ml·kg-1·min-1,modality was continuous venous-venous hemofiltration （CVVH） and major cause was non-sepsis treated with standard dose CRRT. Conclusions Standard dose CRRT in patients with ARF does not improve survival, renal recovery and composite outcome, but decreases mortality in important subgroups including those with higher delivered dose, CVVH and non-sepsis.