社区获得性肺炎伴发急性肾损伤的预后危险因素分析

Analysis of Prognostic Risk Factors in Patients with Community Acquired Pneumonia Complicated with Acute Kidney Injury

目的探讨社区获得性肺炎（CAP）患者伴发急性肾损伤（AKI）的预后危险因素。方法456例CAP患者为无伴发AKI（N-AKI）组和伴发AKI组。AKI组又根据RIFLE的严重程度级别分为3个亚组：危险（Risk）、损伤（Iniury）和衰竭（Failure）组。比较各组患者CAP的严重程度，各项临床指标和预后评估指标的差别；多因素分析采用Logistic回归模型，生存分析采用Kaplan-Meier法，分析影响CAP患者预后不良的危险因素及RIFLE标准在预后评估中作用。结果456例CAP患者中有30％（135例）伴发AKI，诊断为Risk61例（45.2％），Injury23例（17％），Failure51例（37.8％）。CAP患者PSI评分为I一Ⅲ级的患者（300例）中有23.3％（70例）伴发AKI，PSl分级≥IV的患者（156例）中有41.7％（65例）伴发AKI，差异有统计学意义（P〈0.01）。伴发AKI的CAP患者30d病死率随AKI严重程度增加（N-AKI患者6.2％，Risk患者14.8％，Injury患者21.7％，Failure患者45.1％）。此外，随着AKI严重程度增加，需要机械通气、正性肌力药物和肾脏替代治疗的患者比例增加。Logistic回归分析显示合并AKI、〉75岁、合并肾外器官衰竭是住院CAP患者预后不良的危险因素。结论住院CAP患者伴发AKI的预后不良。RIFLE诊断及分级标准可有效评估CAP伴发AKI患者的预后。

Objective To explore clinical characteristics and prognostic risk factors in patients with community acquired pneumonia （CAP）complicated with acute kidney injury（AKI）. Methods In total, 456 CAP patients were included based on the diagnostic guide. According to whether the patients were accompanied with AKI, the patients were divided into two groups （non-AKI group and AKI group）. AKI group were further divided into risk group, injury group and failure group by RIFLE criteria using admission creatinine. Severity in CAP patients, clinical indexes and prognostic evaluation indexes were compared between different groups. Multiple factors were analyzed using Logistic regression model, survivalanalysis were examined by Kaplan-Meier, which analyzed the risk factors of poor prognosis in CAP patients and the role of RIFLE criteria in prognostic evaluation. Results Thirty percent （135） of the total 456 CAP patients were accompanied with AKI. Patients in AKI group were further divided into risked group （45.2%, 61 patients）, injury group （17%, 23 patients） and failure group （37.8%, 51 patients） according to the RIFLE diagnostic criteria using basal creatinine level. Among the 300 patients with PSI grade I to Ⅲ, 23.3% （70） of patients developed AKI while among 156 patients who are with PSI grade Ⅳ or over, 65 patients （41.7%） developed AKI （P 〈 0.01 ）. The 30-day mortality of CAP patients accompanied with AKI were increased compared to Non-AKI group （Non-AKI ： 6.2% ; Risk ： 14.8% ; Injury ： 21.7% ; Failure ： 45.1%）. With deteriorating in RIFLE criteria, the portion of patients who required mechanical ventilation, inotropic support （MV/IS） and renal replacement therapy（RRT）increased too. Logistic analysis revealed that AKI, age of 75 years or older and extrarenal organ failure were the risk factors of poor prognosis in patients with CAP. The rate of survivors was decreased in the CAP patients accompanied with AKI compared with those who did not. Conclusion There is certain incidence of AKI to complicate CAP patients who will have a poor prognosis. RIFLE diagnostic criteria is a valuable tool to evaluate prognosis of CAP patients complicated with AKI.