外科重症患者心肾综合征的临床特点与预后分析

Clinical features and outcomes of patients with the cardio-renal syndrome admitting to a surgical intensive care unit

目的探讨外科重症患者心肾综合征(CRS)的临床特点、预后影响因素及死亡危险因素。方法回顾性分析2017年1月1日至12月31日收入北京大学人民医院外科重症加强治疗病房(SICU)的CRS患者临床资料,收集患者性别、年龄、疾病严重程度、基础疾病、CRS类型、CRS诱因、心肾功能[心肌肌钙蛋白I(cTnI)、B型钠尿肽(BNP)、血肌酐(SCr)、肾小球滤过率(eGFR)]、预后指标[继发感染、机械通气时间、重症加强治疗病房(ICU)住院时间、总住院时间、28d病死率及住院病死率]。根据患者CRS分型或住院预后分组,分析重症患者发生CRS的特点,并采用Logistic回归分析CRS患者住院死亡的危险因素。结果研究期间北京大学人民医院SICU共收治1172例患者,其中有86例(7.3%)患者符合CRS诊断标准。①CRS临床特征:1~5型CRS患者分别占24.4%(21例)、1.2%(1例)、20.9%(18例)、1.2%(1例)、52.3%(45例),说明CRS以1、3、5型为主(即以急性心肾功能障碍为主),而其中5型CRS比例最高(即继发于系统疾病导致的心肾功能同时受累引起器官功能障碍最为常见)。各类型CRS患者间基线BNP、SCr峰值和基线eGFR差异存在统计学意义(Z=11.365,P=0.023;Z=13.405,P=0.009;F=2.648,P=0.037)。1型CRS患者基础心功能明显差于3型和5型CRS患者[基线BNP(μg/L):434.2(187.0,1252.0)比154.9(66.4,272.5)、268.5(124.1,486.6),均P<0.05];3型CRS患者基础肾功能明显差于5型CRS患者[基线eGFR(mL/min):71.0±30.3比88.3±29.0,P<0.05];3型CRS患者发生急性肾损伤(AKI)程度明显重于1型和5型CRS患者[SCr峰值(μmol/L):285.0(171.5,420.6)比143.0(99.5,213.5)、189.0(105.5,280.5),均P<0.01];而各类型CRS患者间性别、年龄、科室来源、入科急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、术中出血量、基线cTnI和SCr水平、BNP峰值、AKI分期及预后指标差异均无统计学意义。②死亡风险分析:86例CRS患者中住院期间死亡43例,病死率高达50%。与CRS存活患者相比,CRS死亡患者年龄更大[岁:72(57,80)比62(50,73)],入院时病情更重[APACHEⅡ(分):22(17,29)比18(15,21)],合并基础疾病中脑血管病的发生率更高(9.3%比0),发生CRS的诱因中脓毒症/脓毒性休克的比例和手术应激的比例更高(41.9%比18.6%,9.3%比0),cTnI峰值和SCr峰值更高[cTnI(μg/L):1.155(0.192,5.125)比0.122(0.045,0.610),SCr(μmol/L):208(143,295)比146(101,289)],发生AKI3期的比例更高(41.9%比20.9%),继发感染的比例更高(67.4%比30.2%),机械通气时间和ICU住院时间更长[h:179(61,470)比37(7,134);d:10(4,24)比5(2,11)],差异均有统计学意义(均P<0.05)。Logistic回归分析显示:高龄[优势比(OR)=1.053,95%可信区间(95%CI)=1.003~1.094,P=0.010]、高APACHEⅡ评分(OR=1.165,95%CI=1.057~1.285,P=0.002)、发生脓毒症/脓毒性休克(OR=4.561,95%CI=1.351~15.391,P=0.014)和AKI3期(OR=5.468,95%CI=1.457~20.530,P=0.012)是CRS患者住院死亡的独立危险因素。结论外科重症患者发生CRS的特点以急性心肾功能障碍为主,5型CRS最为多见,且病死率高。高龄、病情危重、发生脓毒性休克和AKI3期是SICU中CRS患者住院死亡的独立危险因素。

Objective To investigate the clinical features and risk factors on outcomes of patients with cardio-renal syndrome(CRS)in surgical intensive care unit(SICU).Methods The clinical data of the patients admitted to SICU of Peking University People's Hospital from January 1st 2017 to December 31st 2017 were analyzed retrospectively,including gender,age,severity of the disease,underlying diseases,type of CRS,precipitating factors of CRS,cardiac and renal function [cardiac troponin I(cTnI),B-type natriuretic peptide(BNP),serum creatinine(SCr),glomerular filtration rate(eGFR)],outcomes [secondary outcomes,duration of mechanical ventilation,the length of ICU stay,the length of hospital stay,28-day mortality and hospital mortality].Patients were grouped according to CRS classification or hospitalization prognosis,the clinical features within different CRS types were analyzed,and risk factors on outcomes of the CRS patients were analysed by Logistic regression.Results 86(7.3%)of the 1172 patients during the study period had CRS.①CRS clinical features:CRS 1-5 type patients accounted for 24.4%(21 cases),1.2%(1 case),20.9%(18 cases),1.2%(1 case)and 52.3%(45 cases)respectively,CRS type 1,3 and 5 were the main types(i.e.acute cardiac and renal dysfunction),while type 5 CRS was the highest(i.e.organ dysfunction caused by simultaneous involvement of cardiac and renal functions secondary to systemic diseases was the most common).Baseline BNP(Z=11.365,P=0.023),SCr peak(Z=13.405,P=0.009)and baseline eGFR(F=2.648,P=0.037)were significantly different within the CRS 5 types.The basic cardiac function of type 1 CRS patients was significantly worse than that of type 3 and type 5 CRS patients [baseline BNP(μg/L):434.2(187.0,1252.0)vs.154.9(66.4,272.5),268.5(124.1,486.6),both P<0.05].The basic renal function of type 3 CRS patients was significantly worse than that of type 5 CRS patients [baseline eGFR(mL/min):71.0±30.3 vs.88.3±29.0,P<0.05].The severity of acute kidney injury(AKI)in type 3 CRS patients was significantly higher than that in type 1 and type 5 CRS patients [SCr peak(μmol/L):285.0(171.5,420.6)vs.143.0(99.5,213.5),189.0(105.5,280.5),both P<0.01].There were no significant differences in gender,age,department,acute physiology and chronic health evaluationⅡ(APACHEⅡ),intraoperative blood loss,basic cTnI and SCr levels,BNP peak,AKI staging and prognostic indicators among patients with various types of CRS.② Death risk analysis:43(50%)of the 86 CRS patients died during the hospital stay.Compared with the survival patients,CRS death patients were older [years old:72(57,80)vs.62(50,73)] and had higher APACHEⅡ score [22(17,29)vs.18(15,21)],with higher proportion of cerebrovascular disease(9.3% vs.0).Regarding to precipitating factors of CRS,sepsis/septic shock(41.9% vs.18.6%)and surgery stress(9.3% vs.0)were remarkably increased in death patients.Death patients had higher cTnI and SCr peak [cTnI peak(μg/L):1.155(0.192,5.125)vs.0.122(0.045,0.610),SCr peak(μmol/L):208(143,295)vs.146(101,289)] and also high proportion of AKI stage 3(41.9% vs.20.9%),higher rate of secondary infection(67.4% vs.30.2%),prolonged duration of mechanical ventilation and the length of ICU stay [hours:179(61,470)vs.37(7,134);days:10(4,24)vs.5(2,11)],with statistically significant differences(all P<0.05).Logistic regression analysis showed that the elderly [odds ratio(OR)= 1.053,95% confidence interval(95%CI)= 1.003-1.094,P=0.010],high APACHE Ⅱ score(OR=1.165,95%CI=1.057-1.285,P=0.002),sepsis/septic shock(OR=4.561,95%CI=1.351-15.391,P=0.014)and AKI stage 3(OR=5.468,95%CI=1.457-20.530,P=0.012)were independent risk factors for hospital death in CRS patients.Conclusions Surgical ICU patients with CRS are characterized by acute cardiac and renal dysfunction.CRS type 5 is the most common and has a high fatality rate.Age,severity of illness,sepsis/septic shock and AKI stage 3 are independent risk factors of death.