重症监护病房收治重症活动性狼疮性肾炎患者的临床特征及转归

Clinical characteristics and outcomes of critical patients with active lupus nephritis in renal intensive care unit

目的:探讨重症监护病房(ICU)收治的重症活动性狼疮性肾炎(LN)患者的临床特点及预后。方法:收集2010年1月至2019年12月国家肾脏疾病临床医学研究中心ICU收治的450例活动性LN患者,回顾性分析重症LN入住ICU的病因、器官损伤特征和预后。结果:450例活动性LN中,168例(37.3%)合并感染。最常受累器官是肾脏(100%),其余依次为中枢神经系统(19.8%)、心脏(15.8%)、消化系统(8.7%)、肺(4.7%)和血液系统(4.7%),多器官损伤占4.2%。79例(17.6%)合并血栓性微血管病(TMA),多器官损伤和伴心脏损伤者TMA比例高达36.8%和35.1%。246例(54.7%)接受肾脏替代治疗,3个月内摆脱透析率为53.3%。转出ICU后28d和3个月死亡率分别为7.6%和10.9%,合并感染者3个月死亡率显著高于无感染者(15.9%vs 7.9%,P=0.011)。3个月肾脏存活率为72.3%,LN合并TMA患者肾脏存活率明显低于无TMA者(61.8%vs 74.6%,P=0.025)。COX多因素分析示,感染、中枢神经系统和多器官损伤是患者3个月内死亡的独立危险因素;年龄和血液系统损伤是3个月内无法摆脱透析的独立危险因素。结论:ICU收治的重症活动性LN患者TMA和感染发生率高,器官损伤严重,人肾预后差,需要早期识别,采取有效治疗手段改善预后。

Objective:To investigate the clinical characteristics and prognosis of critical patients with active lupus nephritis(LN).Methodology:A total of 450 LN patients admitted to the renal intensive care unit(ICU)of the National Clinical Research Center of Kidney Diseases,from January 2010 to December 2019 were included in the study.The etiology,organ involvement and prognosis of patients were retrospectively analyzed.Results:Among the 450 LN patients,168(37.3%)were complicated with infection.The most common involved organ injury was kidney(100%),followed by central nervous system(19.8%),heart(15.8%),gastrointestinal tract(8.7%),lung(4.7%)and hematology(4.7%).Multiple organ involvement accounted for 4.2%.79 patients(17.6%)were diagnosed with thrombotic microangiopathy(TMA),and the incidence of TMA was higher in those with multiple organ(36.8%)and cardiac involvement(35.1%).246 patients(54.7%)received renal replacement therapy and 53.3%of them recovered.The 28-day and 3-month post-ICU discharge mortality rate was 7.6%and 10.9%.The mortality rate of patients with infection was significantly higher than other(15.9%vs 7.9%,P=0.011).The 3-month renal survival rate was 72.3%,and the renal survival of patients with TMA was significantly lower than the others(61.8%vs 74.6%,P=0.025).COX multivariate analysis showed that infection,central nervous system injury and multiple organ involvement were independent risk factors for 3-month survival.Age and hematological injury were independent risk factors of poor renal survival.Conclusion:Critical patients with active LN who have a high incidence of TMA and infection were often complicated with various organ involvement,and had poor patient and renal survival.Early identification and effective treatment are essential to improve the prognosis.