血清营养学指标预测住院急性肾损伤患者早期死亡

Serum nutritional markers are predictors of early mortality in hospital-acquired acute kidney injury

目的 评价血清营养学指标对住院期间发生急性肾损伤（ AKI）的患者的预后,特别是早期死亡和晚期死亡的预测价值.方法 采用前瞻性队列研究.入选华山医院住院期间发生AKI的成人患者194例.AKI诊断标准为RIFLE分期中的Scr标准,除外肾后梗阻、原发性肾小球肾炎、间质性肾炎及血管炎引起的AKI.收集患者临床资料及实验室检测指标,用人体测量、血清营养指标及主观全面评价法（SGA）来评估患者的营养状况.根据存活时间是否超过28 d,将入选患者分为存活组129例（存活＞28 d）与死亡组59例（存活≤28 d）.进一步将死亡组分为早期死亡组（存活≤7d）和晚期死亡组（存活8～28 d）两个亚组.观察各项营养指标对AKI患者预后的预测价值.结果 人体测量、血清营养指标及SGA结果显示,高比例的AKI患者存在营养不良.单因素分析显示,SGA、血清前白蛋白及胆固醇、外周血总淋巴细胞计数（TLC）、Maastricht指数（MI）在早期死亡组、晚期死亡组和存活组间差异有统计学意义.早期死亡组前白蛋白及胆固醇显著低于存活组和晚期死亡组（P＜0.05）.多因素分析显示,在校正了年龄、性别、透析、机械通气、血红蛋白、血小板、血清胆红素和Glasgow昏迷评分（GCS）后,SGA及血清白蛋白、前白蛋白、胆固醇仍与早期死亡相关.以白蛋白、前白蛋白、胆固醇预测早期死亡的受试者工作特征（ ROC）曲线下面积（AUC）分别为0.591、0.736和0.603,前白蛋白的AUC显著大于白蛋白及胆固醇（均P＜0.05）.结论 低水平前白蛋白、白蛋白和胆固醇可独立预测住院期间发生AKI患者的早期死亡.

Objective To evaluate the role of nutritional parameters in prognosis,especially in the early and late mortality of hospital-acquired acute kidney injury （AKI） patients.Methods This study was a prospective cohort study conducted in a hospital comprising 1500 beds in Shanghai, China. One hundred ninety-four patients with hospital-acquired AKI, as determined using the RIFLE staging criteria,were enrolled as subjects after obtaining informed consent.Patients with AKI caused by postrenal obstruction,glomerulonephritis,interstitial nephritis or vasculitis were excluded.Nutritional evaluation,including subjective global assessment （SGA）,anthropometric and laboratory examination,was conducted. Other laboratory measurements and clinical data were recorded.The primary outcome was early mortality （≤ 7 days） and late mortality （8-28 days） after enrolling into the study. Results AKI patients at enrollment were characterized by a high prevalence of malnutrition as determined by SGA, anthropometric and laboratory examination.Univariate analysis showed that the SGA,the serum levels of prealbumin,cholesterol and total lymphatic cells, and the Maastricht index were significantly different among early mortality,late mortality and survival groups.The serum prealbumin and cholesterol levels in the early death group were significantly lower than those in the survival and late death groups （P〈0.05）.Multivariate analysis revealed that SGA,albumin,prealbumin and cholesterol remained independently and significantly associated with early mortality after adjusting for age,sex,dialysis,ventilation,hemoglobin,platelets,bilirubin,and Glasgow coma score.The areas under the receiver operating characteristic curve to predict early mortality for albumin,prealbumin and cholesterol were 0.591,0.736 and 0.603,respectively,with that of prealbumin significantly higher than others （P〈0.05）. Conclusion Low levels of serum prealbumin,albumin and cholesterol at enrollment are independtly associated with increased early mortality in hospital-acquired AKI patients.