肾脏替代治疗时间对重症急性肾衰竭患者预后的影响

Impact of therapeutic time on the prognosis in critically ill patients with acute renal failure who needed renal replacement therapy

目的探讨肾脏替代治疗（RRT）时间对重症急性肾衰竭（ARF）患者预后的影响及死亡危险因素。方法所有患者的资料来自上海市卫生局“ARF的早期发现与防治”课题数据库。88例重症ARF并行连续性静－静脉血液滤过（cVVH）患者，其中男56例，女32例；年龄（55．73±16．33）岁。根据单次治疗时间将患者分为短时组（6～12h，49例）和长时组（〉12h，39例），分别比较两组患者治疗前的一般情况和治疗前后各项参数的变化情况，采用Kaplan—Meier生存曲线分析比较两组患者发生ARF后15、30、60d的生存率，采用Cox回归分析死亡危险因素。结果治疗前两组患者在年龄、手术情况、慢性肾脏病史、糖尿病史、肾外器官衰竭数和疾病危重程度等方面均无明显差异。两组患者单次治疗后血pH值、HCO3^-、K^＋、尿素氮（BUN）、血肌酐（SCr）均有显著改善，而Na^＋、心率（HR）、平均动脉压（MAP）则差异无统计学意义。Kaplan—Meier生存曲线分析显示：短时组和长时组ARF患者治疗后15、30、60d生存率分别为64．4％比51．4％，52．8％比46．2％及50．4％比41．O％，Log—Rank检验两组各时段生存率差异均无统计学意义（P=1．234）。Cox回归分析提示糖尿病[危险度（HR）为2．134，95％可信区间（95％讲）1．093～4．167，P〈0．053和肾外器官衰竭数（日尺为1．564，95％CI1．233-1．984，P〈O．01）是影响患者预后的独立危险因素。结论RRT后重症ARF患者的病死率仍较高；在CVVH治疗保证一定置换剂量的情况下，6～12h和〉12h治疗时间对于重症ARF患者的短期预后可能影响不大；糖尿病和多器官功能衰竭是重症ARF患者死亡的独立危险因素。

Objective To investigate the impact of therapeutic time on the prognosis in critically ill patients with acute renal failure （ARF） who needed renal replacement therapy （RRT）, and to analyze the risk factors of death. Methods All data were retrieved from the Database of Early Diagnosis and Treatment in Acute Renal Failure in Shanghai. Eighty-eight patients were collected with 56 males and 32 females who accepted continuous veno-venous hemofiltration （CVVH）. The mean age was （55.7±16.33） years old. Patients were divided into two groups according to therapeutic time： short time group （6 - 12 hours, n= 49） and long time group （〉12 hours, n= 39）. The differences between two groups before and after treatment were compared. Kaplan-Meier survival analysis, the Log-rank test was performed to evaluate the prognosis of ARF patients on 15, 30 and 60 days. Cox regression analysis was performed to evaluate the risk factors affected the patient survival. Results There were no significant difference of age, surgery, chronic kidney disease （CKD）, diabetes, multiple organ failure （MOF） and severity of disease between two groups before treatment. Compared with that before treatment, blood pH, HCO3- were increased, and K^＋, blood urea nitrogen （BUN）, serum creatinine （SCr） were decreased after treatment （all P〈0. 05）. There were no significant difference of Na^＋ concentration and heart rate （HR）, mean arterial pressure （MAP） after treatment. Kaplan-Meier survival analysis showed the survival rate of short time group and long time group were 64. 4% vs. 51.4%, 52. 8% vs. 46. 2% and 50. 4% vs. 41.0% on 15, 30 and 60 days respectively. No significant difference in survival rate was noted （P = 1.234）. Cox regression analysis showed that the independent risk factors of short time mortality were diabetes [hazard ratio （HR）=2.134, 95% confidence interval （95%CI） 1. 093 - 4. 167, P 〈 0. 05] and MOF （HR 1. 564, 95%CI 1. 233 - 1. 984, P〈0. 01）. Conclusion The mortality of ARF in critical ill patients remains high, despite accepted renal replacement therapy. The therapeutic time of CVVH may not affect the patient survival not with standing the duration of renal replacement therapy. In our group, diabetes and MOF were the independent risk factors of patients death.