感染性休克致急性肾损伤的血流动力学特征及对预后的意义

The hemodynamic characteristic and prognosis significance of acute kidney injury caused by septic shock

目的探讨感染性休克致急性肾损伤（AKI）的血流动力学特征及预后意义。方法回顾性分析2001年1月-2008年6月北京协和医院加强医疗科收治的放置肺动脉导管的感染性休克患者158例AKI的发病率和病死率，并进行生存分析和预后评价。观察血流动力学参数对AKI发病的影响。结果158例感染性休克患者中126例发生AKI（79．7％），其中AKI1期发病率为20．6％（26／126），AKI2期发病率为20．6％（26／126），AKI3期发病率为58．7％（74／126）；45．6％（72／158）的患者需要肾脏替代治疗。158例患者中28d病死率为59．5％（94／158），发生AKI者死亡90例，28d病死率为71．4％（90／126），其中AKI1期病死率为38．5％，AKI2期病死率为69．5％，AKI3期病死率为83．8％。生存分析显示，AKI1、2、3期的28d生存率依次降低，ROC曲线下面积为0．811，95％CI为0．738—0．883，P〈0．001。平均动脉压控制在90～100mmHg（1mmHg=0．133kPa），AKI发病率为76．2％；控制在80～90mmHg，AKI发病率为71．8％；控制在65～80mmHg，AKI发病率为94．4％。心指数（CI）控制在〉4．0L·min^-1·m^-2，AKI发病率为76．7％；控制在2．5～4．0L·min^-1·m^-2，AKI发病率为71．2％；控制在〈2．5L·min^-1·m^-2，AKI发病率为96．6％。结论感染性休克所致AKI发生率高，预后差；AKI的分期可作为感染性休克预后的一个独立预测因子。感染性休克时全身血流动力学改变在AKI发生中起重要作用，提高血压和CI有助于减少AKI发生，但过高的血压和CI并不能进一步减少AKI发生。

Objective To study the incidence of acute kidney injury （AKI） in patients with septic shock, evaluate the impact of AKI stage on the prognosis of septic shock and explore the role of hemodynamics in the incidence of AKI. Methods We retrospectively investigated the patients of septic shock who had been placed pulmonary artery catheter（PAC） continuously admitted in Peking Union Medical College Hospital from January,2001 to June,2008. Mortality and incidence of AKI were compared between groups of different AKI stages, survival analysis and prognosis evaluation were performed. The impacts of hemodynamics on the incidence of AKI were studied. Results Altogether 158 cases of septic shock were enrolled in this retrospective study. Of all the patients, the incidences of all AKI and stage 1-3 were 79. 7% （126/158）, 16. 5% （26/158）, 16. 5% （26/158） and 46. 8% （74/158） respectively; 45. 6% （72/158） of all the patients needed renal alternative therapy. Ninety-four patients died within 28 days （59. 5% ）. The mortality in the patients without AKI was 12. 5%, while those with AKI and those at stages 1-3 of AKI were 38.5%, 69. 2%, 83.8% and 71.4% （P〈0.05）, with OR values at 4. 38, 15.75,36. 17 and 17. 50 respectively. The survival analysis showed that the survival rate decreased as AKI stage increasing. The ROC curve showed that the area under curve （AUC） was 0. 811 ,with 95% CI at 0. 738-0. 883 （P 〈0. 001 ）. The incidences of AKI in patients with different levels of mean arterial pressure （mAP） were 76. 2% （ 9 0 - 100 mm Hg ） , 7 1. 8 % （ 80-90 mm Hg ） and 9 4.4 % （ 65-80 mm Hg ） respectively. The incidences ofAKI in patients with different levels of cardiac index （CI） were 76. 7% （ 〉4. 0 L·min^-1·m^-2） ,71.2% （2. 5-4.0L·min^-1·m^-2） and 96. 6%（ 〈2.5 L·min^-1·m^-2）.Conclusion Septic shock is highly associated with AKI and has poor prognosis. AKI stage of AKI net is an independent predictor of prognosis of septic shock. The change of hemodynamics has an important role on the development of septic AKI. It＇s useful to decrease the incidence of AKI by elevating the blood pressure and CI, but super-normal goal won＇t work better.