医学文献解读

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Title and abstract

Title:Association between metformin use on admission and outcomes in intensive care unit patients with acute kidney injury and type 2 diabetes: A retrospective cohort study

We included patients with AKI and type 2 diabetes (T2DM) from the Medical Information Mart for Intensive Care database. The 30-day mortality, neutrophil-to-lymphocyte ratio, and length of hospital stay were compared between patients with and without metformin prescriptions.Metformin use may be associated with reduced risk-adjusted mortality in patients with AKI and T2DM

Introduction

Background/rationale

Acute kidney injury (AKI) occurs in more than half of intensive care unit patients. Effective prevention and treatment strategies for AKI remain limited.

Objectives

We aimed to assess AKI-related mortality in patients with diabetes who were metformin and non-metformin users

Methods

Study design

子主题

A retrospective cohort study

Setting

We enrolled patients with AKI and T2DM with and without metformin exposure on ICU admission using the Medical Information Mart for Intensive Care (MIMIC)-III (version 1.4).

Participants

Patients with AKI and T2DM were considered eligible for our study; AKI was defined according to the Kidney Disease: Improving GlobalOutcomes (KDIGO) criteria.The diagnosis of T2DM was based on the International Classification of Disease, Ninth Revision.

Variables

We included the following variables: demographic characteristics,and service unit; heart rate, mean arterial pressure (MAP), respiratory rate, SPO2, white blood cell (WBC) count, hemoglobin, platelet count,SCr, blood glucose, simplified acute physiology score (SAPS) II score, ventilator use, vasopressor use, renal replacement therapy (RRT) use,and comorbidities (congestive heart failure liver disease, coronary heart disease stroke, malignancy, and respiratory failure). Vasopressors included norepinephrine, epinephrine, phenylephrine, vasopressin, dopamine, dobutamine, and isoprenaline. We also included marital status and insurance.

Data sources

the Medical Information Mart for Intensive Care (MIMIC)-III (version 1.4).

Bias

Continuous variables were expressed as mean and standard deviation (SD) for normal distributions or median and interquartile range for skewed distributions. We used the chi-square test, one-way ANOVA, and KruskalWallis test for the comparison of categorical, normally distributed, and non-normally distributed continuous variables, respectively.

Study size

We included only adult patients (age > 16 years). For patients with recurrent ICU admissions, only the first ICU admission was considered.

Quantitative variables

The following variables were selected to generate the propensity score: age, sex, ethnicity, marital status, insurance, admission type, service unit, heart rate, MAP, respiratory rate, SPO2, WBC count, SCr, hemoglobin, platelet count, ventilator use, vasopressor use, RRT use and SAPS II score

Statistical methods

Descriptive analysis was performed for all participants. Categorical variables were expressed as numbers and percentages. Continuous variables were expressed as mean and standard deviation (SD) for normal distributions or median and interquartile range for skewed distributions. We used the chi-square test, one-way ANOVA, and KruskalWallis test for the comparison of categorical, normally distributed, and non-normally distributed continuous variables, respectively.

Other information

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.

Discussion

Key results

Our findings suggested that metformin use was associated with lower risk-adjusted mortality in patients with AKI and T2DM.

Our

fifi ndings suggested that metformin use was associated with

lower risk-adjusted mortality in patients with AKI and T2DM.

Limitations

First, the potential for residual confounding may exist, as with all retrospective analyses

Second, the studypopulation was comprised only patients with AKI and T2DM; therefore,our findings may not be generalizable to patients with AKI and type 1diabetes

Third, we were unable to exclude patients with myocardial infarction during the month prior to admission

Fourth, 18.53% (802) patients did not have SCr measurement before ICU admission.

Fifth, the record of metformin in “Medications on admission” was likely to be more prone to unrecorded in this study.

Interpretation

Metformin users with AKI and T2DM in our study were fewer than those previously reported; however, it is noteworthy that the potential exposed misclassification resulting from such errors would bias toward the null, thus, resulting in an underestimation of the association between metformin use and 30-day mortality.

Generalisability

Results

Participants

We identified 4328 individuals with T2DM who developed AKI according to the KDIGO definition. Of these patients, 998 (23%) used metformin.

Descriptive data

The demographic characteristics of all participants are presented in Table 1. After PSM, of 982 pairs matched. The mean age was 67.0 ± 12.6 years; 797(40.6%) were women, 1376 (70.1%) were whites, and 588 (29.9%) were non-whites. The numbers of patients in each AKI stage were 817, 774 and 373 for stages 1, 2, and 3, respectively (Table 1

Outcome data

Only include type 2 diabetes patients(29,698patients excluded),8,907 patients with type 2 diabetes,Olny include AKI patients (4,578 patients excluded)4,328 patiens included

Main results

The 30-day mortality rates were 15.7% (523/3330) and 9.0% (90/ 998) for non-metformin and metformin users, respectively .

Other analyses

multivariable Cox proportional hazards regression analysis similarly demonstrated that metformin was associated with a reduced hazard for 30-day mortality (HR = 0.54; 95% CI, 0.43–0.69, P < 0.0001) (Table 2).