慢性肾脏病基础上的急性肾损伤患者的临床分析

Acute-on-chronic kidney disease patients: a clinical analysis

目的探讨慢性肾脏病基础上肾功能急性减退（acute-on-chronic kidney disease,ACKD）患者发病的基本情况、诱发因素、治疗选择及疗效和预后,以期降低ACKD的发病率。方法回顾性分析2011年1月~2012年2月在兰州大学第二医院肾内科住院ACKD患者的诱发原因、易感疾病、治疗、疗效和预后。结果 ACKD患者共55例,占同期入院患者的4.6%。肾病综合征、慢性间质性肾炎及糖尿病肾病患者极易发生ACKD,诱发ACKD的常见原因分别为感染（30.9%）、原发病加重（29.1%）和使用致肾脏损伤的药物（12.7%）。治疗有效患者38例,积极控制原发病（59.5%）、有效治疗感染（10.5%）及停用致肾脏损伤药物（2.6%）是ACKD患者肾功能逆转的重要措施;无效患者17例,与治疗有效的患者相比,其高血压、高血压肾损害及并发合并症的患者比例较高（P〈0.05）。随访44例,治疗有效组29例,治疗无效组15例。随访时间7.1±3.8月。2组比较：肾功能好转率分别为34.2%比5.9%,P〈0.05,肌酐倍增率分别为23.7%比29.4%,终末期肾衰竭发生率分别为7.9%比29.4%,P〈0.05,死亡率分别为10.5%比23.5%。12个月肌酐倍增发生率分别为：有效组17%,无效组62%（P〈0.05）。高血压及存在合并症是发生肌酐倍增的风险因素。结论 ACKD不能有效逆转则使肾脏预后恶劣,对CKD尤其是肾病综合征、慢性间质性肾炎及糖尿病肾病的患者管理中,应谨防感染、治疗不正规及使用可能致肾脏损伤药物等诱发ACKD的因素,及早救治极为迫切。

Objective To investigate the clinical information, induced factors, therapies, and prognosis in patients with acute renal injury on the basis of chronic kidney disease （CKD） （acute-on-chronic kidney dis- ease, ACKD） in order to reduce morbidity in these patients. Methods Data from ACKD patients during the period from Jan., 2011 to Feb., 2012 were collected, and their induced factor, underlying disease, therapy and outcome were retrospectively analyzed. Results Fifty-five ACKD patients accounting for 4.6% of hospital- ized patients in the same period were included in this study. Nephrotic syndrome, chronic interstitial nephritis and diabetic nephropathy were highly susceptible to ACKD. The common causes inducing ACKD included in- fection （30.9%）, aggravation of underlying diseases （29.1%）, and nephrotoxic drug （12.7%）. Thirty-eight ACKD patients responded effectively to therapies, and the effective therapies to reverse the renal function in- cluded control of the primary diseases （59.5%）, treatment of infections （10.5%）, and interruption of nephrotox- ic drug administration （2.6%）. The therapies were ineffective in 17 ACKD patients, in which the prevalence of hypertension, hypertensive nephropathy and its comorbidities were higher than that in effective ACKD pa- tients （P〈0.05）. Twenty-nine effective patients and 15 ineffective patients were followed up for 7.1 ~ 3.8 months. In the effective patients and ineffective patients, percentage of renal function improvement was 34.2% and 5.9%, respectively （P〈0.05）, percentage of doubling serum creatinine level was 23.7% and 29.4%, respectively, percentage of end-stage renal failure was 7.9% and 29.4%, respectively （P〈0.05）, and the mortality was 10.5% and 23.5%, respectively. The incidence of doubling serum creatinine in 12 months was 17% and 62% in the effective patients and ineffective patients, respectively （P〈0.05）. Hypertension and its comorbidities were the risk factors for doubling serum creatinine level. Conclusions The prognosis of ACKD is poor in patients with nephrotic syndrome, chronic interstitial nephritis and diabetic nephropathy when no effective treatment is administered. The risk factors for ACKD including infections, inappropriate therapies and nephrotoxic drugs should be managed promptly.