Objective: To evaluate the efficacy of early goal-directed renal replacement therapy (GDRRT) in patients with severe pneumonia associated acute kidney injury (AKI). Methods: Patients with severe pneumonia and diagnosed with AKI, and underwent GDRRT at Zhongshan Hospital between January 1, 2017 and December 31, 2022 were retrospectively enrolled. All patients were divided into early RRT group and regular RRT group according to fluid status, inflammation progression, and hemodynamics at RRT initiation.The primary endpoint was in-hospital all-cause mortality, and the secondary endpoints included recovery of renal function at discharge, and 90-day and 1-year all-cause mortality. The multivariate Cox regressionwas employed to analyze therelationship between timing of RRT initiation and patient's prognosis. Results: A total of 170 patients aged (71±13) years were enrolled, including 122 males (71.8%). There were 86 and 84 cases in the early and regular RRT groups, respectively. No statistically significant differences of demographic characteristics were detected between the two groups (all P>0.05). At RRT initiation, the patients in the early RRT group displayed a lower percentage of fluid load [2% (1%, 3%) vs 3% (2%, 4%), P<0.001], lower rate of using high-dose of vasoactive agents [11.6% (10/86) vs 40.5% (34/84), P<0.001] and higher rate of radiographic progression within 72 h in the intensive care unit (ICU) [58.1% (50/86) vs 33.3% (28/84), P<0.001] than those in the regular RRT group. The all-cause in-hospital mortality was significantly lower in the early RRT group than that in regular RRT group [37.2% (32/86) vs 67.9% (57/84), P<0.001]. Patients in the early RRT group displayed a significantly higher proportion of complete renal recovery at discharge [44.2% (38/86) vs 7.1% (6/84), P<0.001]. The 90-day [46.5% (40/86) vs 82.1% (69/84), P<0.001] and 1-year [65.1% (56/86) vs 92.9% (78/84), P<0.001] mortality were significantly lower in the early RRT group. Multivariate Cox proportional hazards regression model revealed that the early initiation of GDRRT significantly decreased the risk of in-hospital mortality (HR=0.57, 95%CI: 0.37-0.88, P=0.011). Conclusion: This study indicates that early GDRRT for the treatment of severe pneumonia-associated AKI based on fluid status, hemodynamics and inflammation progression is associated with reduced hospital mortality and better recovery of renal function.
目的： 评估早期目标导向肾脏替代治疗（GDRRT）在重症肺炎相关急性肾损伤（AKI）患者中的应用效果。 方法： 回顾性选取2017年1月1日至2022年12月31日在复旦大学附属中山医院诊断为重症肺炎相关AKI并接受GDRRT的住院患者，将肾脏替代治疗（RRT）启动时AKI分期较低、容量负荷程度高、炎症反应重、血流动力学相对稳定的患者划分至早期组，反之划分至常规组。主要终点为院内全因死亡率，次要终点包括出院时肾功能恢复情况、90 d和1年全因死亡率。采用多因素Cox回归分析RRT启动时机与预后的关系。 结果： 纳入170例接受GDRRT的重症肺炎患者，年龄（71±13）岁，男122例（71.8%）。早期组86例，常规组84例，两组年龄、性别等人口学特征差异均无统计学意义（均P>0.05）。与常规组相比，早期组容量负荷较低［2%（1%，3%）比3%（2%，4%），P<0.001］、使用大剂量血管活性药物比例较低［11.6%（10/86）比40.5%（34/84），P<0.001］、入重症监护病房（ICU）72 h内肺部影像学进展率较高［58.1%（50/86）比33.3%（28/84），P<0.001］。与常规组相比，早期组的院内全因死亡率较低［37.2%（32/86）比67.9%（57/84），P<0.001］，出院时肾功能完全恢复率较高［44.2%（38/86）比7.1%（6/84），P<0.001］。早期组90 d［46.5%（40/86）比82.1%（69/84），P<0.001］和1年［65.1%（56/86）比92.9%（78/84），P<0.001］全因死亡率低于常规组。多因素Cox回归分析结果显示，早期启动RRT可降低重症肺炎相关AKI患者院内死亡的风险（HR=0.57，95%CI：0.37~0.88，P=0.011）。 结论： 在重症肺炎相关AKI患者中根据容量、血流动力学和炎症状态为指导，进行早期GDRRT可降低院内死亡率，促进肾功能恢复。.