脓毒症伴急性肾损伤患者连续性肾脏替代治疗时机的探讨

Timing of continuous renal replacement therapy in sepsis patients with acute kidney injury

目的探讨脓毒症伴急性肾损伤(AKI)患者连续性肾脏替代治疗(CRRT)最佳开始时机。方法选择浙江省人民医院ICU在2011年1月至2015年1月期间收治的脓毒症伴AKI并接受CRRT治疗的112例成年患者,根据CRRT治疗前的KDIGO-AKI分期,将处于AKI-1期或2期的患者归于早期组(52例),而AKI-3期的患者则归于晚期组(60例)。比较两组患者的急性病生理学和长期健康评价(APACHE)Ⅱ评分、序贯器官衰竭评分(SOFA)、平均动脉压、乳酸水平、WBC、血红蛋白、血小板计数、机械通气时间、ICU住院时间、28 d生存率、住院病死率情况。同时采用Kaplan-Meier生存分析法绘制早期组和晚期组患者的生存曲线,并用Log-Rank检验进行比较分析。结果两组患者CRRT治疗前的APACHEⅡ评分、平均动脉压、乳酸水平、血小板计数等方面比较,差异均无统计学意义(P均>0.05),与早期组患者比较,晚期组患者的SOFA评分[(9.6±4.3)分vs.(7.4±2.9)分,t=3.171,P=0.002]、WBC[(15±8)×109/L vs.(12±9)×109/L,t=2.273,P=0.025]及住院病死率[70%(42/60)vs.50.0%(26/52),χ2=4.672,P=0.031]更高,血红蛋白含量[(89±25)g/L vs.(100±27)g/L,t=2.107,P=0.037]、28 d生存率[40.0%(24/60)vs.61.54%(32/52),χ2=5.169,P=0.023]更低。而两组患者的平均机械通气时间和ICU住院时间比较,差异均无统计学意义(P均>0.05)。Kaplan-Meier生存曲线提示,早期组患者的生存率高于晚期组患者(χ2=12.169,P<0.001)。结论脓毒症伴AKI患者病死率高,CRRT的最佳介入时机应早于患者肾功能进展至AKI-3期时。

Objective To explore the optimal timing for continuous renal replacement therapy（CRRT） in sepsis patients with acute kidney injury（AKI）. Methods A total of 112 sepsis patients with AKI treated with CRRT in ICU of Zhejiang Provincial People＇s Hospital from January 2011 to January 2015 were divided into the early CRRT group（AKI-stage 1 or stage 2, 52 cases） and late CRRT group（AKI-stage 3, 60 cases） according to their Kidney Disease：Improving Global Outcomes（KDIGO）-AKI stage before initiation of CRRT. The acute physiology and chronic health evaluation（APACHE） Ⅱ score, sequential organ failure（SOFA） score, mean arterial pressure, serum lactate, WBC, hemoglobin, blood platelet count, duration of mechanical ventilation, length of ICU stay, 28 d survival rate and fatality rate of inpatient were compared between the two groups. Kaplan-Meier curves obtained with the Log-rank test were plotted to demonstrate the differences in patients＇ survival between the two groups. Results There were no significant differences between the two groups in APACHE Ⅱ score, mean arterial pressure,serum lactate and blood platelet count before CRRT（all P〉0.05）. In the late CRRT group, the SOFA score [（9.6 ± 4.3） vs.（7.4 ± 2.9）, t = 3.171, P = 0.002], WBC [（15 ± 8） × 109/ L vs.（12 ± 9） × 109/ L,t = 2.273, P = 0.025] and fatality rate of inpatient [70%（42 / 60） vs. 50.0%（26 / 52）, χ2= 4.672,P = 0.031] were much higher, and hemoglobin [（89 ± 25） g / L vs.（100 ± 27） g / L, t = 2.107, P =0.037], 28 d survival rate [40.0%（24 / 60） vs. 61.54%（32 / 52）, χ2= 5.169, P = 0.023] were much lower than those in the early CRRT group. However, the duration of mechanical ventilation and length of ICU stay showed no significant differences between the two groups（all P〉0.05）.Furthermore, the Log-rank test of Kaplan-Meier curves also showed that survival rate in the early CRRT group was better than that in the late RRT group（ χ2= 12.169, P〈0.001）. Conclusion The mortality is really high in patients with sepsis-associated AKI, and the optimal timing of initiating CRRT may predate in patients with early renal progress to AKI-3 phase.