不同发病时间的急性肾损伤对急性心力衰竭患者转归的影响

Impact on onset time of acute kidney injury on outcomes of patients with acute heart failure

目的探讨不同发病时间的急性肾损伤（AKI）对急性心力衰竭（AHF）患者转归的影响。方法连续性入选2011年10月~2013年8月在我院住院并诊断为AHF的患者371例,分为早发型（入院起4天内）和迟发型（入院5天以后）AKI,比较两组患者的预后差异。AKI定义为48h内血清肌酐水平较基础值≥0.3mg/dl或上升1.5倍。主要终点事件为出院后12个月的死亡率。结果 371例患者中,共有99例发生AKI,早发型AKI为50例,迟发型AKI为49例。迟发型AKI患者入院后血清肌酐最大增幅高于早发型患者（P=0.012）,而且这些患者的12个月死亡率高于早发型AKI患者（对数秩和检验,P=0.014）。迟发型AKI是12个月死亡的独立危险因素（风险比：3.39,95%CI：1.84~6.18,P〈0.001）。迟发型AKI与入院时高血尿素氮和静脉注射多巴酚丁胺有关。结论高血尿素氮和静注多巴酚丁胺相关的迟发型AKI与高死亡率有关,而早发型AKI与高死亡率无关。观察AKI发病时间有助于对发生AKI的AHF患者死亡风险进行评估。

Objective To study the impact on onset time of acute kidney injury （AKI） on outcomes in patients with acute heart failure （AHF）. Methods A total of 371 AHF patients were included. The impact of AKI （≥0.3mg/dl or 1.5-fold increase in serum creatinine level within 48h） with early onset （≤4days from admission） or late onset （≥5days from admis- sion） was assessed. Results AKI occurred in 99 patients, 50 cases with early onset of AKI and 49 cases with late onset of AKI. The maximum increase in serum creatinine level from admission was greater in patients with late onset of AKI than in patients with early onset of AKI （P=O.O12）. Patients with late onset of AKI had a higher 12-month mortality rate than that of patients with early onset of AKI （log-rank test, P=0.014）. Late onset of AKI was an independent predictor of mortality （hazard ratio： 3.39,95% confidence interval： 1.84-6.18, P〈0.001 ）. Late onset of AKI was associated with high blood urea nitrogen level at admission and intravenous administration of dobutamine. Conclusion Late onset of AKI is related to high blood urea ni- trogen level and intravenous administration of dobutamine, but early onset of AKI is not linked to high mortality rate. Onset time of AKI may be useful for risk stratification of mortality in AHF patients developing AKI.