感染性休克伴急性肾损伤的临床研究

Clinical study of acute kidney injury in septic shock

目的分析感染性休克伴有急性肾损伤(AKI)患者的临床特征和高危因素,探讨感染性休克发生AKI的原因。方法回顾性分析112例感染性休克的临床资料,根据急性肾损伤网络(AKIN)分期将感染性休克患者分为不伴有急性肾损伤组(NAKI组)、AKI 1期组、AKI 2期组、AKI 3期组,比较四组患者的临床特征、实验室指标、抗生素使用及液体复苏情况,并分析了AKI的发生与预后的关系。结果 AKI组的APACHEⅡ评分明显高于NAKI组(P<0.05),AKI 2期组与AKI 3期组血p H和HCO-3低于NAKI组和AKI 1期组(P<0.05),AKI 2期组与3期组的C-反应蛋白(CRP)高于NAKI组和AKI 1期组(P<0.05);AKI组使用升压药≥2种例数多于NAKI组(P<0.05);AKI组的补液量(休克初6 h)明显多于NAKI组(P<0.05);随AKI病情加重需行机械通气例数明显增多(P<0.05﹚;并且随AKI病情加重,器官损害个数逐渐增加(P<0.05)。随着AKI分期的增加,患者的病死率逐渐上升;患者休克后抗生素使用的耽误时间越长,AKI发生的可能性越大,预后不佳。结论感染性休克中急性肾损伤的发生率高,提示预后不良。AKI的发生与休克的严重性、全身炎症反应的程度、不适当的液体过负荷及延迟的抗生素使用密切相关。在感染性休克的救治过程中密切监测血流动力学状态,避免液体过负荷,尽早使用有效抗生素或可降低AKI的发生,改善预后。

Objective To describe the clinical characteristics and risk factors associated with early acute kidney injury （AKI）in septic shock,and investigate the causes of AKI in patients with septic shock.Methods Data of 112 cases with septic shock were collected retrospectively in a single center,which are divided into four groups：NAKI,AKI stage 1,2,and 3based on AKIN staging,to mutually compare clinical features,laboratory data,ways of using antibiotics and fluid resuscitation ,and to analyze the relationship between the occurrence of AKI and the prognosis.Results The APACHE Ⅱscore of AKI group is apparently higher than that of NAKI group （P〈0.05）,the blood PH and HCO3 - of the AKI stage 2 and 3 groups are lower than those of NAKI and AKI stage 1 groups （P 〈0.05）,while the CRP of the AKI stage 2 and 3 groups is higher than NAKI and AKI stage 1 groups （P 〈0.05）;the cases of using two or more kinds of vasopressors in AKI group are more than NAKI group （P 〈0.05）.The amount of preliminary rehydration （shock early 6 hours）of AKI group is obviously more than NAKI group （P 〈0.05）.Along with the aggravation of AKI,the need of mechanical ven-tilation significantly increases （P 〈0.05）,and the number of impaired organ increases gradually as well （P 〈0.05）.With the increase of AKI staging,the mortality is also rising.The longer the delay of the use of antibiotics in patients with shock was,the greater the chance of AKI occurred,and a poor prognosis would come.Conclusions The occurrence rate of acute kidney injury in septic shock is high,with poor outcome.The occurrence of AKI is closely associated with the severity of the shock,the extent of systemic inflammatory response,inappropriate fluid overload and the delayed use of antibiotics.In the process of treatment of septic shock,closely monitoring the hemodynamic status,avoiding fluid overload,using effective antibiotics as soon as possible could decrease the incidence of AKI and improve the prognosis of patients.