Hemodiálise prolongada na lesão renal aguda associada a sepse: sobrevida dos pacientes de acordo com o momento da indicação e a dose de diálise recebida
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2016-02-26
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Abrão, Juliana Maria Gera [UNESP]
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Universidade Estadual Paulista (Unesp)
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Introdução - A mortalidade de pacientes com Lesão Renal Aguda (LRA) que necessitam de suporte renal agudo (SRA) é elevada. Alguns estudos sugerem que o SRA indicado tardiamente associa-se a piores desfechos. Outros, avaliando dose de diálise, não encontraram benefício com uso de SRA mais intenso. Entretanto, são escassos os trabalhos que avaliaram estes tópicos em pacientes dialisados por Hemodiálise Prolongada (HDP) e considerando a LRA exclusivamente associada a sepse. Objetivo - Avaliar a sobrevida de pacientes com LRA associada a sepse, submetidos a HDP, de acordo com o momento da indicação e a dose de diálise recebida. Material e Métodos - Coorte retrospectiva de pacientes críticos com LRA associada a sepse, estágio 3 segundo classificação AKIN, submetidos a HDP, de abril de 2008 a outubro de 2014, em dois hospitais de referência em nefrologia. De acordo com o momento da indicação do SRA, os pacientes foram divididos em grupo SRA precoce (início até 24 horas após atingido estágio 3 da LRA) e SRA tardio (início depois de 24 horas após atingido estágio 3 da LRA). A dose de diálise obtida por sessão foi calculada e, de acordo com a média do Kt/V semanal recebido, os pacientes também foram divididos em grupo SRA intenso (Kt/V maior ou igual a média) e grupo SRA menos intenso (Kt/V menor que a média). O desfecho estudado foi mortalidade intra-hospitalar. Considerado nível de significância de 5%. Resultados - Foram estudados 361 pacientes, com média de idade de 59,7 ± 15,7 anos, sendo 65,6% homens. No diagnóstico da LRA AKIN 3, 62,1% apresentavam oligúria. A mortalidade intra-hospitalar foi de 82,5%. Em 54% dos casos o SRA foi tardio e a média do Kt/V semanal foi de 6,59 ± 1,6. Entre os pacientes que evoluíram para óbito foram observados maior média de idade (61,1 ± 14,8 versus 53,1 ± 18,3 anos; p=0,002), maior ATN-ISS (0,65 versus 0,60; p=0,002), maior percentagem de oligúricos (66,4 versus 41,3%; p<0,001) e menor creatinina sérica (3,6 versus 4,4 mg/dL). Neste mesmo grupo, houve mais indicação tardia de SRA, com tendência à diferença estatística (56,4% versus 42,9%; p=0,05). O Kt/V semanal foi semelhante entre os grupos óbito e não óbito. A análise multivariada mostrou que idade (OR=1,03; p<0,001), SRA tardio (OR=1,91; p=0,033) e oligúria (OR=2,83; p=0,001) foram associados a maior risco de óbito, enquanto maior valor de creatinina (OR=0,86; p=0,048) foi fator de proteção. Houve maior mortalidade no grupo SRA tardio, com tendência a diferença estatística (86,2% versus 78,3%; p=0,05) e foi observada melhor curva de sobrevida no subgrupo de pacientes oligúricos submetidos a SRA precoce (p=0,016). A mortalidade (82,2% no grupo SRA intenso versus 82,8% no grupo SRA menos intenso; p=0,888) e as curvas de sobrevida foram semelhantes nos grupos SRA intenso e SRA menos intenso. Conclusão – Quando avaliados pacientes com LRA associada a sepse e dialisados com HDP, a indicação precoce do SRA está associada a menor mortalidade, em especial entre pacientes oligúricos, e não há benefício em fornecer diálise mais intensa.
Introduction - The mortality of patients with Acute Kidney Injury (AKI) requiring Acute Renal Support (ARS) is high. Some studies suggest that ARS indicated lately is associated with worse outcomes. Other, assessing dialysis dose, found no benefits with an intense use of ARS. However, few studies assessed those topics in dialyzed patients under extended hemodialysis and considering the Acute Kidney Injury exclusively associated with sepsis. Objective - To assess survival in patients with AKI associated with sepsis subject to extended hemodialysis according to the time of prescription and dialysis dose received. Material and Methods - Retrospective cohort of critically ill patients with AKI associated with sepsis, stage 3, according to AKIN classification, subjected to extended hemodialysis, from April 2008 to October 2014, in two referral hospitals in nephrology. According to the time of ARS indication patients were divided into early ARS group (beginning within 24 hours of reaching Stage 3 of AKI) and late ARS (beginning after 24 hours of reaching Stage 3 of AKI). Dialysis dose obtained by session was calculated and according to the average of weekly Kt/V received, patients were also divided into heavy ARS group (Kt/V ≥ average) and less intense ARS group (Kt/V < average). The study outcome was in-hospital mortality, considering a significance level of 5%. Results - 361 patients were studied aged between 59.7 ± 15.7 years old and 65.6% men. In AKI AKIN 3 diagnosis, 62.1% presented oliguria. In-hospital mortality was 82.5%. In 54% of the cases the ARS was late and the average of weekly Kt/V was 6.59 ± 1.6. Among the patients who died, it was observed higher mean age (61.1 ± 14.8 versus 53.1 ± 18.3 years; p = 0.002), higher ATN-ISS (0.65 versus 0.60; p = 0.002), higher percentage of patients with oliguria (66.4 vs. 41.3%; p <0.001) and lower serum creatinine (3.6 vs. 4.4 mg / dl). In this same group, there was more of later indication of ARS, prone to statistical difference (56.4% versus 42.9%; p = 0.05). The weekly Kt/V was similar between the death and non- death groups. Multivariate analysis showed that age (OR = 1.03; p <0.001), late ARS (OR = 1.91; p = 0.033) and oliguria (OR = 2.83; p = 0.001) were associated with increased risk of death, while higher values of creatinine (OR = 0.86; p = 0.048) was a protective factor. There was a higher mortality rate in the late ARS group, prone to statistical difference (86.2% versus 78.3%; p = 0.05) and was observed better survival rate in the subgroup of patients with oliguria undergoing the early ARS (p = 0.016 ). The mortality (82.2% in the intense ARS group versus 82.8% in the less intense ARS group; p = 0.888) and survival curves were similar between the groups intense and less intense ARS. Conclusion - In patients with AKI associated with sepsis and dialyzed with Extended Hemodialysis the early indication of ARS is associated with lower mortality especially among patients with oliguria and there is no benefit in providing more intensive dialysis.
Introduction - The mortality of patients with Acute Kidney Injury (AKI) requiring Acute Renal Support (ARS) is high. Some studies suggest that ARS indicated lately is associated with worse outcomes. Other, assessing dialysis dose, found no benefits with an intense use of ARS. However, few studies assessed those topics in dialyzed patients under extended hemodialysis and considering the Acute Kidney Injury exclusively associated with sepsis. Objective - To assess survival in patients with AKI associated with sepsis subject to extended hemodialysis according to the time of prescription and dialysis dose received. Material and Methods - Retrospective cohort of critically ill patients with AKI associated with sepsis, stage 3, according to AKIN classification, subjected to extended hemodialysis, from April 2008 to October 2014, in two referral hospitals in nephrology. According to the time of ARS indication patients were divided into early ARS group (beginning within 24 hours of reaching Stage 3 of AKI) and late ARS (beginning after 24 hours of reaching Stage 3 of AKI). Dialysis dose obtained by session was calculated and according to the average of weekly Kt/V received, patients were also divided into heavy ARS group (Kt/V ≥ average) and less intense ARS group (Kt/V < average). The study outcome was in-hospital mortality, considering a significance level of 5%. Results - 361 patients were studied aged between 59.7 ± 15.7 years old and 65.6% men. In AKI AKIN 3 diagnosis, 62.1% presented oliguria. In-hospital mortality was 82.5%. In 54% of the cases the ARS was late and the average of weekly Kt/V was 6.59 ± 1.6. Among the patients who died, it was observed higher mean age (61.1 ± 14.8 versus 53.1 ± 18.3 years; p = 0.002), higher ATN-ISS (0.65 versus 0.60; p = 0.002), higher percentage of patients with oliguria (66.4 vs. 41.3%; p <0.001) and lower serum creatinine (3.6 vs. 4.4 mg / dl). In this same group, there was more of later indication of ARS, prone to statistical difference (56.4% versus 42.9%; p = 0.05). The weekly Kt/V was similar between the death and non- death groups. Multivariate analysis showed that age (OR = 1.03; p <0.001), late ARS (OR = 1.91; p = 0.033) and oliguria (OR = 2.83; p = 0.001) were associated with increased risk of death, while higher values of creatinine (OR = 0.86; p = 0.048) was a protective factor. There was a higher mortality rate in the late ARS group, prone to statistical difference (86.2% versus 78.3%; p = 0.05) and was observed better survival rate in the subgroup of patients with oliguria undergoing the early ARS (p = 0.016 ). The mortality (82.2% in the intense ARS group versus 82.8% in the less intense ARS group; p = 0.888) and survival curves were similar between the groups intense and less intense ARS. Conclusion - In patients with AKI associated with sepsis and dialyzed with Extended Hemodialysis the early indication of ARS is associated with lower mortality especially among patients with oliguria and there is no benefit in providing more intensive dialysis.
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Palavras-chave
Dose de diálise, Hemodiálise prolongada, Lesão renal aguda, Indicação de diálise, Oligúria, Sepse, Suporte renal agudo, Dialysis dose, Extended hemodialysis, Acute renal injury, Dialysis prescription, Sepsis, Acute renal support