非ST段抬高型急性心肌梗死患者急性肾损伤危险因素分析

Analysis of risk factors for acute kidney injury in patients with non-ST-segment elevation myocardial infarction

目的探讨非sT段抬高型急性心肌梗死（non-ST-segment elevation myocardial infarction,NSTEMI）患者发生急性肾损伤（acute kidney injury，AKI）的危险因素，初步建立AKI的预警评分。方法选择2011年1月至2014年4月从广东汕头市中心医院急诊科转移到心血管内科的NSTEMI患者296例。回顾性收集患者的人口统计学资料、发生AKI前后的临床资料和实验室检查结果。根据患者住院后是否发生AKI分为AKI组和非AKI组。以单因素分析筛选出有统计学意义的危险因素，再通过多元逐步Logistic回归分析确定NSTEMI患者住院后发生AKI相关独立危险因素，进而根据各危险因素的比值比（OR值），初步建立预警评分，应用受试者工作特征（ROC）曲线下面积（AUC）评价其分辨能力，采用Hosmer—Lemeshow拟合优度检验评价其校准能力。结果共入选296例NSTEMI患者，AKI发病率为18．4％，其中AKⅡ期35例（64．8％），AKIⅡ期12例（22．2％），AKIⅢ期7例（13．0％）；Logistic回归分析显示：年龄、心功能Killip分级、贫血、发病至急诊科时间，未使用B一受体阻滞剂是NSTEMI患者住院后发生AKI的独立危险因素；进而初步建立NSTEMI患者发生AKI的预警评分，总分为各独立危险因素评分之和，最高分为13分，根据约登指数，预测AKI风险的最佳界值为3．5分，从而获得评分系统的风险分层标准为：评分≤3．0分预示低危风险，评分≥4．0分预示高危风险。初步建立AKI评分系统分辨能力较高（AUC=0．806，P〈0．01），具有较好的校准能力（Hosmer—Lemeshow拟合优度检验P=0．503）。结论年龄、心功能Killip分级、贫血、发病至急诊科时间，未使用β-受体阻滞剂是NSTEMI患者住院后发生AKI的独立危险因素；初步建立的AKI预警评分可能有助于急诊医师早期识别高危AKI患者并进行积极干预。

Objective To investigate the risk factors for acute kidney injury （AKI） in patients with non- ST-segment elevation myocardial infarction （ NSTEMI）, and to establish a prediction score system for AKI. Methods Totally 296 patients with NSTEMI, who were admitted to the emergency room and further transferred to the Cardiovascular Department in Shantou Central Hospital, were enrolled during January 2011 to April 2014. All patients were divided into AKI group and non-AKI group. Demographics, clinical data and laboratory examinations were collected before and after AKI. AKI risk factors and its OR values were determined after statistically analyzed data by One-Way ANOVA, multivariate logistic regression analysis. Prediction score system for AKI was further established by area under the ROC curve and Hosmer-Lemeshow goodness of fit tests. Results For total 296 patients, the incidence of AKI was 18.4%, including 35 （64. 8% ） patients in stage Ⅰ, 12 （22. 2% ） patients in stage Ⅱ and 7 （ 13.0% ） patients in stage Ⅲ. Logistic analysis showed that age, heart function （Killip）, anemia, the time to emergency department after AMI attack, and absence It-blockerwere independent factors associated with AKI. Prediction score system was established which the highest score was 13. A risk score of 3.5 points was determined by Youden＇ s index, as the optimal cut-off for predict AKI. Patients with ≤3.0 points were considered at low risk, and ≥4. 0 points were considered at high risk for AKI. The prediction score system of AKI showed adequate discrimination （ area under ROC curve was 0. 806 ） and calibration （ Hosmer-Lemeshow statistic test, P = 0. 503 ）. Conclusions Age, heart function （ Killip ）, anemia, the time to emergency department after AMI attack, and absence β-blocker were independent factors associated with AKI, The clinical prediction score system may help clinicians to make pre-intervention for NSTEMI patients with high AKI risk.