连续性肾脏替代治疗1型心肾综合征患者的预后及影响因素

Prognosis and influence factors of patients with type 1 cardiorenal syndrome requring continuous renal replacement

目的:对常规治疗无效的心肾综合征(CRS)可用连续性肾脏替代治疗(CRRT),通过回顾性观察性研究,描述接受CRRT治疗的1型CRS患者的起始特征、终止特征及预后。方法:本研究纳入2009年5月至2015年4月在南京医科大学第一附属医院住院并行CRRT治疗的1型CRS患者。按患者90d是否死亡或是否摆脱透析分为摆脱透析组、透析依赖组和死亡组。记录3组患者一般情况、心肾功能、合并症、CRRT前用药、CRRT起始特征(血清肌酐、血清尿素氮、尿量、出入量平衡)、终止特征和预后,并使用单因素和多因素COX回归分析患者死亡的危险因素。结果:研究纳入52例患者,男性27例、女性25例,平均年龄70.7±16.1岁。平均APACHEⅡ评分为14.4±4.2,平均SOFA评分为8.7±4.7。52例患者死亡率为65.4%。摆脱透析患者开始CRRT前中位尿量及出入量平衡(入量-出量)与透析依赖组、死亡组有明显差异。摆脱透析患者终止CRRT时中位尿量、出入量平衡显著大于透析依赖组(P<0.05)。多因素COX回归分析显示低左室射血分数、低血清白蛋白、高APACHEⅡ评分和出入量正平衡是死亡的独立危险因素。结论:需行CRRT的1型CRS患者预后差,死亡的独立危险因素包括营养状况、心功能、疾病严重程度和容量平衡,死亡组相比存活组在治疗前液体正平衡更明显。尿量至少达到1 000 ml/24h、容量达负平衡时可考虑终止CRRT。

Objective： To explore initiating and ending clinical feature,as well as the prognosis of continuous renal replacement therapy（ CRRT） in patients with type 1 cardio-renal syndrome（ CRS）. Methodology： Fifty-two patients who were admitted for type 1 CRS from May 2009 to April 2015 and carried out CRRT in the Jiangsu Province Hospital were enrolled into this retrospective study. They were divided into three groups according to the prognosis- renal replacement therapy（ RRT） independence,RRT dependence and death. The three groups were compared in the baseline index,diagnosis,complication,drugs before CRRT,CRRT initiating indications and the prognosis. Results： They were27 males and 25 females with the mean ages of 70. 7 ± 16. 1 years old. The mean APACHE II scores and SOFA scores were14. 4 ± 4. 2 and 8. 7 ± 4. 7,respectively. Mortality rate was 65. 4%. The mean urine output of RRT independence group was 800 ml /24 h,much greater than that of RRT dependence group（ 650 ml） and death group（ 345 ml） before the initiation of CRRT. Additionally,the fluid balance were obviously different among the three group（ 167 ml、250 ml、1 270 ml,respectively）. At the ending of CRRT,the mean urine output and fluid balance were remarkably different between RRT independence and RRT dependence group（ 1 350 ml vs 265 ml,- 460 ml vs 760 ml）. A multivariate Cox regression approach showed that the risk factors for death were low left ventricular ejection fraction,low serum albumin,high APACHE II scores and positive fluid balance. Conclusion： Refractory type 1 CRS using CRRT for rescue therapy was associated with high mortality. The risk factors for death were low left ventricular ejection fraction,low serum albumin,high APACHE II scores and positive fluid balance. The mean fluid balance of survivors（ RRT dependence and RRT independence） were remarkably less than the death group at the initiating time of CRRT. Meanwhile,when the urine output of patients reached to 1 000 ml /24 h and the volume balance was negative,terminating CRRT could be considered.