甘露醇是脑外伤患者发生急性肾损伤的独立危险因素

Mannitol is an independent risk factor of acute kidney injury in traumatic brain injury patients

目的 探讨脑外伤患者发生急性肾损伤（AKI）的危险因素,并评价甘露醇在其中的作用.方法 回顾性分析2006年1月至2008年12月间复旦大学华山医院神经外科急救中心收治的脑外伤患者AKI的发生情况.AKI诊断采用RIFLE分期标准.采用Logistic回归分析脑外伤患者发生AKI的危险因素,建立脑外伤患者AKI发生的预测模型,并运用接受者操作特性（ROC）曲线及曲线下面积评价该模型对预测脑外伤患者并发AKI的敏感性和特异性.采用倾向性得分匹配法（PSM）进一步分析甘露醇对脑外伤患者发生AKI的影响.结果 共入选符合标准的脑外伤患者171例,其中AKI组53例,非AKI组118例.患者平均年龄（45.92±16.50）岁.单因素分析结果显示,年龄、高血压、急诊手术、系统性炎性反应综合征（SIRS）、Glasgow昏迷评分、序贯器官衰竭评估（SOFA）评分、SOFA呼吸评分、SOFA凝血评分、SOFA心血管评分、机械通气天数、红细胞悬液累计输注总量、血浆累计输注总量、呋塞米累计总剂量、托拉塞米累计总剂量、甘露醇累计总剂量是脑外伤患者发生AKI的危险因素.多因素Logistic回归分析显示,SOFA评分（OR=1.516,95%CI 1.222～1.881,P〈0.01）、托拉塞米累计总剂量（OR=0.016,95%CI 1.002～1.031,P=0.016）、甘露醇累计总剂量（OR=2.687,95%CI1.062～6.800,P=0.037）是脑外伤患者发生AKI的独立危险因素.运用ROC曲线及曲线下面积评价由SOFA评分、托拉塞米累计总剂量和甘露醇累计总剂量3个变量组成的多因素Logistic回归模型对脑外伤患者发生AKI预测的敏感性和特异性,结果显示ROC曲线下面积为0.901（P〈0.01）,提示该模型对预测脑外伤患者AKI的发生具有良好的敏感性和特异性.倾向性得分匹配法分析结果显示甘露醇总剂量是脑外伤患者发生AKI的独立危险因素.结论 AKI是脑外伤患者住院期间常见的并发症.SOFA评分、托拉塞米累计总剂量、甘露醇总剂量是脑外伤患者发生AKI的独立危险因素.

Objective To explore the risk factors of acute kidney injury （AKI） in patients with brain trauma and to investigate the role of mannitol. Methods A random cohort of traumatic brain injury patients who were admitted to Neurosurgical Emergency Center of Huashan Hospital, Fudan University from January 2006 to December 2008 was studied. AKI was determined using RIFLE staging criteria for changes in serum ereatinine （Scr）. By means of Logistic regression analysis, the risk factors of AKI were investigated, and a predictive model was established. Discrimination of the model was assessed using the receiver operating characteristic （ROC） curve. Association between single independent risk factor and AKI was depicted with ROC curve. Adjustment for selection bias was further assessed using propensity score match （PSM） to evaluate the role of mannitol in the development of AKI. Results A total of selected 171 patients were enrolled in the study, including 53 patients in AKI group and 118 patients without AKI as control group. The average age of these 171 patients was （45.92±16.50） years old. Univariate analysis revealed that age, hypertension, emergent surgery, systemic inflammatory response syndrome （SIRS）, Glasgow coma score （GCS）, sequential organ failure assessment （SOFA） score, respiration component of the SOFA score, coagulation component of the SOFA score, cardiovascular component of the SOFA score, mechanical ventilation time, red blood cell transfusion, plasma transfusion, accumulative dose of furosemide, accumulative dose of torasemide and accumulative dose of mannitol were significantly associated to AKI in patients with brain trauma. Logistic multivariate regression analysis showed that SOFA score （OR =1.516, 95% CI 1.222-1.881, P〈O.01）, accumulative dose of torasemide （OR=0.016, 95%CI 1.002-1.031, P=0.O16） and accumulative dose of mannitol （OR=2.687, 95%C1 1.062-6.800, P=0.037） were independent risk factors of AKI. This model had a good discrimination for AKI with an area under the ROC curve of 0.901 （P〈0.01）. The accumulative dose of mannitol was identified as a risk factor of AKI by PSM test. Conclusions AKI is a common complication in patients with traumatic brain injury. SOFA score, accumulative dose of torasemide and accumulative dose of mannitol are independent risk factors of AKI following traumatic brain injury.