基于KDIGO分级的早期连续性肾脏替代治疗对重症急性肾损伤患者预后的影响

Effect of early initiation of continuous renal replacement therapy based on the KDIGO classification on the prognosis of critically ill patients with acute kidney injury

目的：探讨基于改善全球肾脏病预后组织（KDIGO）分级的早期连续性肾脏替代治疗（CRRT）对重症急性肾损伤（AKI）患者预后的影响。方法回顾性分析2011年1月至2015年1月入住浙江省人民医院重症医学科诊断为AKI患者的临床资料，要求纳入患者年龄≥18岁，重症加强治疗病房（ICU）住院时间＞48h，并接受CRRT治疗。根据KDIGO-AKI指南将研究对象分为AKI1、2、3级组。比较3组患者在一般情况、原发病、病情严重程度、机械通气时间、ICU住院时间、总住院时间、28d存活率及住院病死率等方面的差异；采用logistic回归分析筛选影响重症AKI患者28d存活率和住院病死率的独立危险因素。结果共纳入重症AKI患者258例，其中AKI1级64例，AKI2级62例，AKI3级132例；28d存活116例，存活率为44.96%；出院时死亡154例，住院病死率达59.69%。脓毒症、心力衰竭、药物或毒物中毒是重症患者发生AKI最常见的诱发因素（分别占35.66%、19.38%和13.18%），且AKI1、2、3级3组间诱发因素较为一致。AKI1、2、3级组间血管活性药物使用率（31.25%、41.94%、50.00%，χ2＝6.241，P＝0.044）、急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分（分：20.87±7.37、17.19±7.02、22.58±7.95，F＝5.292，P＝0.006）、序贯器官衰竭评分〔SOFA （分）：8.41±3.46、6.22±2.43、9.58±3.71，F＝10.328，P＝0.000〕差异均有统计学意义；而3组患者在性别、年龄、病例来源、入科至CRRT开始时间、平均动脉压（MAP）、乳酸（Lac）、24h乳酸清除率（LCR）、机械通气时间、ICU住院时间、总住院时间、28d存活率及住院病死率等方面差异均无统计学意义（均P＞0.05）。多因素logistic回归分析显示，入科至CRRT开始时间和Lac水平为影响重症AKI患者28d存活率及住院病死率的独立危险因素〔28d存活率的优势比（OR）分别为0.850和0.774，95%可信区间（95%CI）分别为0.752～0.960和0.638～0.940，P值分别为0.009和0.010；住院病死率的OR值分别为0.884和0.756，95%CI分别为0.781～1.000和0.610～0.939，P值分别为0.049和0.011〕。结论基于KDIGO-AKI分级的早期CRRT未能改善重症AKI患者的预后，重症AKI患者的最佳RRT开始时机还有待进一步探索。

Objective To investigate the impact of early initiation of continuous renal replacement therapy （CRRT） based on ＆quot;Kidney Disease： Improving Global Outcomes （KDIGO）＆quot; classification on the prognosis of critically ill patients with acute kidney injury （AKI）. Methods A retrospective analysis of clinical data of patients diagnosed as AKI in Department of Critical Care Medicine of Zhejiang Provincial People＆#39;s Hospital from January 2011 to January 2015 was conducted. All patients included should be 18 years old or older, having stayed in intensive care unit （ICU） for more than 48 hours, and received CRRT. All subjects were divided into three groups according to their renal function before CRRT according to the KDIGO-AKI guideline： AKI-stage 1 group, AKI-stage 2 group and AKI-stage 3 group. The general condition, original disease, severity of disease, duration of mechanical ventilation, the length of ICU or hospital stay, 28-day survival rate and in-hospital mortality rate were compared among these three groups. Additionally, risk factors for the 28-day survival rate and hospital mortality of critically ill patients with AKI were screened by logistic regression analysis. Results A total of 258 critically ill patients with AKI were enrolled, with 64 cases in AKI-stage 1 group, 62 cases in AKI-stage 2 group, and 132 cases in AKI-stage 3 group. 116 patients survived with 28-day survival rate of 44.96%. 154 patients died with hospital mortality 59.69%. The precipitating factors of AKI in all three groups （stage 1, stage 2, and stage 3） were similar, with sepsis, heart failure and poisoning （drugs or poison） being the main triggers for AKI, accounting for 35.66%, 19.38% and 13.18%, respectively. There were significant differences in the rate of vasoactive agent usage （31.25%, 41.94%, 50.00%, χ2 = 6.241, P = 0.044）, acute physiology and chronic health evaluation Ⅱ （APACHE Ⅱ） score （20.87±7.37, 17.19±7.02, 22.58±7.95, F = 5.292, P = 0.006） and sequential organ failure assessment （SOFA） score （8.41±3.46, 6.22±2.43, 9.58±3.71, F = 10.328, P = 0.000）, while there was no significant difference in gender, age, primary disease, time from ICU admission to the beginning of CRRT, mean arterial pressure （MAP）, lactate level or 24-hour lactate clearance rate （LCR）, mechanical ventilation time, the length of ICU or hospital stay, 28-day survival rate or hospital mortality among these three groups （all P 〉 0.05）. According to the logistic regression analysis, time from ICU admission to start of CRRT and lactate level were the independent risk factors for 28-day survival rate or hospital mortality of critically ill patients with AKI [odds ratio （OR） for 28-day survival rate was 0.850 and 0.774, 95% confidence interval （95%CI） was 0.752-0.960 and 0.638-0.940, P value was 0.009 and 0.010, respectively; OR for hospital mortality was 0.884 and 0.756, 95%CI was 0.781-1.000 and 0.610-0.939, P value was 0.049 and 0.011, respectively]. Conclusion Early initiation of CRRT based on KDIGO-AKI classification could not improve the prognosis of critically ill patients with AKI, the optimal timing of RRT for such patients remains to be further explored.