1型心肾综合征患者接受连续性肾替代治疗的预后影响因素分析

The influence factors on the prognosis in type 1 cardiorenal syndrome treated with continuous renal replacement treatment

目的回顾性分析接受连续性肾替代治疗(continuous renal replacement treatment,CRRT)的1型心肾综合征(cardio-renal syndrome,CRS)患者的临床特征及预后的影响因素。方法收集2008~2016年在首都医科大学附属北京安贞医院因1型CRS接受CRRT治疗的患者。记录患者一般情况、心脏基础疾病、合并症(是否合并高血压、糖尿病)、接受CRRT前肾功能、心功能及联合用药(利尿剂、ACEI/ARB及血管活性药)情况、CRRT的启动时机及除水速度等,按患者是否死亡分为死亡组和生存组,再将生存组分为维持透析组和摆脱透析组,分别使用单因素和多因素COX回归分析患者预后的影响因素。结果研究共纳入53例患者,其中男性36例;平均年龄65.8岁。53例患者死亡23例,死亡率为43.4%;存活患者30例中,肾功能好转摆脱透析者21例,进入维持性透析患者9例。死亡组患者与生存组患者比较,CRRT启动前的尿量明显减少(t=-2.336,P=0.023)、启动CRRT时间晚(t=2.187,P=0.038)、CRRT中低血压的发生率高(χ~2=16.246,P<0.001)、使用血管活性药物比例高(χ~2=12.106,P=0.001)、CRRT后B型脑钠肽(B-type natriuretic peptide,BNP)下降不明显(t=15.931,P<0.001)。摆脱透析组患者的基础血清肌酐(t=-4.796,P=0.001)、CRRT前的血清肌酐(t=-2.502,P=0.018)均明显低于透析依赖组。结论需行CRRT的1型CRS患者死亡率高。死亡的危险因素主要与尿量明显减少提示容量过负荷、CRRT启动过晚、CRRT过程中出现低血压、CRRT后BNP无明显下降等相关;患者的基础肾功能与肾脏预后相关。

Objective To explore clinical features and influence factors on the prognosis in type 1 cardio- renal syndrome （CRS） patients treated with continuous renal replacement therapy （CRRT）. Methods Fifty- three patients admitted to Beijing Anzhen Hospital due to type I CRS and treated with CRRT from January 2008 to March 2016 were enrolled in this retrospective study. They were divided into two groups according to survival or death. Patients in the survival group were further divided into two subgroups according to their prognosis, renal replacement therapy （RRT） independent subgroup and RRT dependent subgroup. Baseline features, diagnosis, complications, combined drug therapy, cardiac function and renal function before CRRT and at the beginning of CRRT were compared respectively between the two subgroups. Results The average age of the 53 patients （36 males and 17 females） was 65.8 years old. Thirty of them were survival with the mortality rate of 43.4%. Twenty-one of the 30 survival patients improved without the need of dialysis any- more, and 9 cases must rely on maintenance dialysis. Compared with the patients in the survival group, pa- tients in the death group had lower urine volume before CRRT （t=--2.336, P=-0.023）, later CRRT beginning time （t=2.187, P=0.038）, higher prevalence of intradialytic hypotension （22= 16.246, P〈 0.001）, higher propor- tion of using vasoactive drugs （2;=12.106, P=0.001）, and less decrease of serum BNP after CRRT （t=15.931, P〈0.001）. In the RRT independent subgroup, serum creatinine at baseline （t=-4.796, P=-0.001） and before CRRT （t=-2.502, P=-0.018） were significantly lower than those in the RRT dependent subgroup. Conclusion The mortality was relatively high in type I CRS treated with CRRT. The risk factors for death were lower urine volume, late beginning of CRRT, intradialytic hypotension, and persistent higher BNP level after CRRT. The risk factor for RRT dependence was the higher baseline serum creatinine before CRRT.