急性心功能不全患者急性肾损伤的发生、危险因素及预后分析

Analysis of incidence, risk factors, and prognosis of acute kidney injury for patients with acute cardiac dysfunction

目的了解急性心功能不全患者重症监护室（ICU）住院期间急性肾损伤（AKI）的发生情况、相关危险因素及预后。方法连续选取2013年4月至2014年7月期间收住仁济医院急诊科ICU的219例确诊急性心功能不全的患者,收集患者的临床资料,进行实验室检查,包括血脑钠肽、血肌酐以及尿蛋白等;根据KDIGO标准将患者分成AKI组和非AKI组,比较2组患者的临床指标、住院时间和患者死亡情况;应用Logistic多元回归法分析急性心功能不全患者发生AKI的危险因素。结果 219例急性心功能不全患者中,发生AKI者81例,发病率为37%;AKI组患者发生急性心功能不全前的基础脑钠肽、基础肌酐以及基础尿蛋白水平均显著高于非AKI组[分别为：155.0（44.5~455.0）pg/m L与113.0（24.3~254.0）pg/m L,P=0.001;89.2（59.2~149.0）μmol/L与68.4（51.0~112.0）μmol/L,P=0.006;20（10~50）mg/d L与10（0~20）mg/d L,P=0.001];AKI组患者心衰时伴发感染、低血压以及使用ACEI/ARB的比例均显著高于非AKI患者（P〈0.05）。多因素回归分析显示,在校正了性别、年龄、糖尿病、高血压、肾毒性药物、基础肌酐值等因素后,慢性肾脏病、感染、应用ACEI/ARB、低血压、脑钠肽较高以及基础尿蛋白增高为急性心功能不全患者发生AKI的独立危险因素;AKI组患者ICU住院时间和住院死亡率显著高于非AKI组[分别为12（10~15）d与11（9~12）d,24%与15%,P均〈0.01]。结论急性心功能不全时患者AKI的发生率较高,慢性肾脏病、感染、应用ACEI/ARB、低血压、脑钠肽较高以及基础尿蛋白增高是这类患者发生AKI的独立危险因素;急性心功能不全患者发生AKI后预后更差,了解和预防AKI的发生及危险因素可以为改善急性心功能不全患者的预后提供依据。

Objective To investigate the incidence, risk factors, and prognosis of acute kidney injury （AKI） for patients with acute cardiac dysfunction in the intensive care unit （ICU）. Methods The clinical data of 219 patients who had diagnosed with acute cardiac dysfunction and treated in the ICU of Department of Emergency Medicine of Renji Hospital from April 2013 to July 2014. Laboratory tests were conducted, including tests for blood brain natrinretic peptide （BNP）, serum creatinine, urinary protein, etc. Patients were divided into the AKI group and non-AKI group according to the KDIGO criteria. The clinical indexes, hospitalization time, and mortality of two groups were compared. Multivariable logistic regression analysis was conducted to identify risk factors of AKI for patients with acute cardiac dysfunction. Results Among 219 patients with acute cardiac dysfunction, 81 （37%） of them developed AKI. The levels of baseline BNP, serum creatinine, and urine protein of the AKI group before the incidence of acute cardiac dysfunction were significantly higher than those of the non-AKI group [155.0（44. 5 -455.0） pg/mL vs 113.0（24.3 -254.0） pg/mL, P=0. 001; 89.2（59.2 - 149.0） lamol/L vs68.4（51.0 -112.0） pmol/L, P=0. 006; and 20（10 -50） mg/dL vs 10（0 -20） mg/dL, P= 0. 001]. The incidences of infection and hypotension and ratio of administration of ACEI/ARB of the AKI group were significantly higher than those of the non-AKI group （P 〈0.05）. The multivariate regression analysis showed that chronic kidney disease, infection, administration of ACEI/ARB, hypotension, high level of BNP, and increase of baseline urine protein were independent risk factors of the incidence of AKI of patients with acute cardiac dysfunction after factors such as gender, age, diabetes, hypertension, renal toxicity drugs, and baseline creatinine level were corrected. The ICU stay and hospital mortality of the AKI group were significantly higher than those of the non-AKI group [12（10 -15） d vs 11（9 -12） d and 24% vs15%, respectively, both P〈0. 01]. Conclusion The incidence of AKI of patients with acute cardiac dysfunction is high. Chronic kidney disease, infection, administration of ACEI/ARB, hypotension, high level of BNP, and increase of baseline urine protein are independent risk factors of the incidence of AKI of patients with acute cardiac dysfunction. The prognosis of patients with acute cardiac dysfunction who develop AKI is poor. Understanding the incidence and risk factors of AKI might provide evidences for improving the prognosis of patients with acute cardiac dysfunction.