危重病评分系统预测急性肾损伤患者预后优于RIFLE分级

General or AKI-specific scoring systems are superior to RIFLE criteria for predicting prognosis in acute kidney injury patients

目的评价并比较序贯性脏器衰竭评分(sequential organ failure assessment,SOFA)、急性生理学与慢性健康状况评分(acute physiology and chronic health evaluation,APACHE)Ⅱ、简明急性生理学评分(simplified acute physiology score,SAPS)Ⅱ和Liano评分4种危重病评分系统及RIFLE标准对急性肾损伤(acute kidney injury,AKI)患者的预后评估价值。方法本研究为前瞻性、单中心研究,收集2008年12月到2009年11月复旦大学附属华山医院各种病因引起的AKI患者。AKI的诊断标准为RIFLE的肌酐标准,除外肾后性、肾小球性、肾血管性和间质性肾炎等引起的急性损伤。研究的主要终点是28d死亡率。比较存活组和死亡组的RIFLE分级、SOFA、APACHEⅡ、SAPSⅡ和Liano评分,并进行各种评分系统对死亡的ROC曲线分析,同时将4种评分方法根据RIFLE分级进行分层分析。结果共入选194例符合入选标准的AKI患者。存活组和死亡组的RIFLE分级、AKI病因、是否需要透析差异无统计学意义(P>0.05)。死亡组的机械通气比例、SOFA、APACHEⅡ、SAPSⅡ和Liano评分显著高于存活组(P<0.001)。SOFA、APACHEⅡ、SAPSⅡ和Liano评分预测死亡的受试者工作特性(ROC)曲线下面积分别为0.900、0.885、0.888、0.875(均P<0.001),而RIFLE的ROC曲线下面积为0.566(P>0.05)。按AKI的RIFLE级别进行分层分析时发现,4个评分方法在衰竭组(Fc)ROC曲线下面积最大,其中又以Liano评分最高。结论 RIFLE分级对AKI患者的预后无明显的判断价值,而危重病评分包括SOFA、APACHEⅡ、SAPSⅡ和Liano评分对AKI的预后具有良好的预测价值。

Objective To evaluate the value of the three general scoring systems （SOFA, APACHE Ⅱ and SAPS Ⅱ）, the AKI-specific scoring system （Liano）, and the RILFE criteria for predicting prognosis in acute kidney injury （AKI） patients. Methods In this prospective and single center study, AKI patients with different causes and hospitalized in this hospital from December 2008 to November 2009 were enrolled. AKI was diagnosed based on the serum creatinine of RIFLE criteria. Patients were excluded from this study if the AKI was due to obstructive uropathy, interstitial nephritis, primary or secondary glomerulonephritis. The primary end point of the study was the mortality after 28 days. Scores from RIFLE classification, SOFA, APACHE Ⅱ, SAPS Ⅱ and Liano scoring systems were compared between the survival and non-survival patients. Receiver operating characteristic （ROC） curve for predicting death was used for the evaluation of scoring systems with and without stratification based on RIFLE classification. Results A total of 194 AKI patients were enrolled in this study. No significant differences were found in RIFLE classification, cause of AKI and dialysis between survivor and death groups. However, ventilation therapy, and scores from SOFA, APACHE Ⅱ, SAPS Ⅱ and Liano systems were significantly different between survivors and non-survivors. Area under ROC （AUROC） curves for predicting death by SOFA, APACHE Ⅱ, SAPS Ⅱ and Liano scores were 0.900, 0.885, 0.888 and 0.875, respectively （P0.001）, which were all higher than the AUROC of RIFLE （0.566, P〉0.05）. Stratification of AKI based on RIFLE classification revealed that patients in the failure group had higher AUROC of the 4 scoring systems, especially the AUROC of Liano scoring system. Conclusions General or AKI-specific scoring systems including SOFA, APACHE Ⅱ, SAPS Ⅱ and Liano systems are superior to RIFLE criteria for predicting prognosis in AKI patients.