重症感染患者多黏菌素B相关急性肾损伤的发生情况及危险因素分析

Occurrence and risk factors of acute kidney injury associated with polymyxin B in patients with severe infection

目的探讨重症感染患者静脉使用多黏菌素B相关急性肾损伤(AKI)的发生情况和危险因素。方法收集2017年10月至2020年10月在中山大学附属第一医院住院期间静脉使用多黏菌素B治疗重症感染患者的电子病历进行回顾性分析,筛选发生多黏菌素B相关AKI的患者,统计分析AKI的发生时间、临床分期和转归,计算多黏菌素B相关AKI发生率以及多黏菌素B用药第3、6、12和15天AKI的累积发生率。根据患者是否发生多黏菌素B相关AKI分为AKI组和非AKI组,比较2组患者的临床特征,应用多因素logistic回归方法分析AKI的危险因素,计算比值比(OR)及其95%置信区间(CI)。结果纳入分析的患者共311例,男性237例(76.2%),女性74例(23.8%);中位年龄58(46,70)岁;52例(16.7%)发生多黏菌素B相关AKI,AKI的发生时间为(4±2)d,范围2~13 d;多黏菌素B用药第3、6、12和15天AKI的累积发生率(%)及其95%CI分别为9.1(3.0~19.4)、15.4(7.9~25.2)、21.5(12.8~31.6)和21.5(12.8~31.6)。发生AKI后,52例患者中17例(32.7%)停用多黏菌素B,其中7例给予连续性肾脏替代疗法(CRRT);35例(53.8%)因病情需要继续用药,其中25例给予CRRT,10例加用利尿剂。经上述处理后,52例患者中22例(42.3%)Scr恢复正常,6例(11.5%)好转,15例(28.9%)因原发病死亡,9例(17.3%)自动出院。多因素logistic回归分析显示,日剂量≥150.0 mg(OR=5.588,95%CI:2.258~13.833,P<0.001)和急性生理学与慢性健康状况评分系统Ⅱ(APACHE‑Ⅱ)评分(OR=1.063,95%CI:1.021~1.106,P=0.003)为多黏菌素B相关AKI的独立危险因素。结论重症感染患者静脉使用多黏菌素B可能在较短的时间内发生AKI,多黏菌素B日剂量≥150.0 mg和高APACHE‑Ⅱ评分可能增加AKI的发生风险。

Objective To investigate the occurrence and risk factors of intravenous polymyxin B-associated acute kidney injury(AKI)in patients with severe infection.Methods Electronic medical records of patients with severe infection treated with intravenous polymyxin B during hospitalization in the First Affiliated Hospital,Sun Yat‑sen University from October 2017 to October 2020 were collected and analyzed retrospectively.Patients with polymyxin B‑induced acute kidney injury were screened out.The occurrence time,clinical stage,and outcome of AKI were statistically analyzed,and the incidence of polymyxin B‑induced AKI and the cumulative incidence of AKI on the 3rd,6th,12th,and 15th days of administration were calculated.Patients were divided into AKI and non‑AKI groups according to whether polymyxin B‑associated AKI occurred.The clinical characteristics in patients of the 2 groups were com‑pared.The risk factors of AKI were analyzed by multivariate logistic regression,and the odds ratio(OR)and 95%confidence interval(CI)were calculated.Results A total of 311 patients were entered in the analysis,including 237 males(76.2%)and 74(23.8%)females,with a median age of 58(46,70)years.Fifty-two patients(16.7%)developed polymyxin B‑associated AKI,and the time from medication to onset of AKI was(4±2)days,ranging from 2 to 13 days.The cumulative incidence(%)of AKI and its 95%CI on the 3rd,6th,12th,and 15th days of polymyxin B administration were 9.1(3.0-19.4),15.4(7.9-25.2),21.5(12.8-31.6),and 21.5(12.8-31.6),respectively.After developing AKI,polymyxin B was discontinued in 17 of 52 patients(32.7%),and 7 of them were given continuous renal replacement therapy(CRRT).The other 35 patients(53.8%)needed to continue medication because of the infection condition,and 25 of them were given CRRT and 10 received diuretics additionally.After the above treatments,22(42.3%)of 52 patients had Scr return‑ing to normal,6 patients(11.5%)were improved,15(28.9%)died due to primary diseases,and 9(17.3%)were discharged under their own request.Multivariate logistic regression analysis showed that daily dose≥150.0 mg(OR=5.588,95%CI:2.258-13.833,P<0.001)and high acute physiology and chronic health evalua‑tionⅡ(APACHE‑Ⅱ)score(OR=1.063,95%CI:1.021-1.106,P=0.003)were independent risk factors for polymyxin B‑associated AKI.Conclusions AKI may occur in a short time in patients with severe infec‑tion after intravenous administration of polymyxin B.The daily dose of polymyxin B≥150.0 mg and high APACHE‑Ⅱscore may increase the risk of AKI.