脓毒症相关急性肾损伤连续肾脏替代治疗危险因素的回顾性分析

A retrospective analysis of risk factors for continuous renal replacement therapy in sepsis associated acute kidney injury patients

目的分析脓毒症相关急性肾损伤(AKI)患者接受连续肾脏替代治疗(CRRT)的相关危险因素,以期为临床CRRT决策提供证据。方法回顾性收集自2009年4月至2014年9月首都医科大学附属北京友谊医院重症医学科收治的年龄>18岁的脓毒症相关AKI患者,根据是否行CRRT分为CRRT组和非CRRT组,比较两组患者一般资料、临床资料、实验室检查结果及临床脏器功能及疾病严重程度评分,Logistic回归分析筛选接受CRRT相关危险因素,受试者工作曲线(ROC)对各因素进一步分析,获得截点值。结果本研究共纳入282例脓毒症相关AKI患者,CRRT组163例,非CRRT组119例。两组间比较住院时间、住ICU时间、铜绿假单胞菌感染比率显著差异(P<0.05)。实验室检查结果提示CRRT组患者贫血程度较非CRRT组重,肾功能、凝血功能相关指标均更差,且乳酸(Lac)水平更高,组织灌注差,容量负荷较重。脏器功能方面两组患者除肺脏功能外均大致相同,但CRRT组患者循环更为不稳定,反映脏器功能衰竭情况及疾病严重程度评分更高。Logistic回归分析提示接受CRRT相关危险因素包括住ICU时间(OR=1.026;P=0.020),APACHE II评分(OR=1.117,P≤0.001),血清肌酐(SCr)水平(OR=1.006,P=0.020),Pa O2(OR=0.993,P=0.006)及PaCO_2(OR=0.974,P=0.012)。各因素截点值(COP)为住ICU时间16.5天,APACHE II评分22.5分,SCr 188.0μmol/L,Pa O281.5 mm Hg,PaCO_239.5 mm Hg。结论 ICU中脓毒症相关AKI患者接受CRRT危险因素包括住ICU时间、APACHE II评分、SCr水平、Pa O2及PaCO_2,上述指标异常预示接受CRRT风险显著增加,临床中应加以关注,以改善患者预后。

Objective To analysis CRRT related risk factors in sepsis associated AKI patients in order to provide evidence for clinical CRRT decision. Methods The data of sepsis associated AKI patients over 18 years of age admitted in the general ICU of Beijing Friendship hospital,Capital medical university between-April 2009 and September 2014,on chronic dialysis or received CRRT before/ICU admission,were retrospectively collected. The patients were divided into the CRRT group and the non-CRRT group according to whether they received CRRT,two groups＇ normal statistics,clinical statistics,laboratory results and clinical organ functions and the APACHE II score were compared. Logistic regression model was used to evaluate the CRRT related risk factors. The discrimination power of those factors was assessed by the receiver operating characteristic（ ROC） curve and then analyzed the cutoff point（ COP）. Results This study included 282 sepsis associated AKI patients,163 of them were on CRRT. The comparison of hospital duration days,ICU duration days,infection of Pseudomonas aeruginosa between two groups showed significant difference（ P〈0. 05）. The laboratory tests showed that CRRT group had more anemia,and even worse levels of kidney function,coagulation function,and higher lactic acid level,and poor tissue perfusion and fluid overload. And except for the lung function,other organ functions between two groups were familiar,while the CRRT group had unstable circulation and higher scores represented organ failure and severity of disease. Logistic regression showed that the CRRT related risk factors were ICU duration days（ OR = 1. 026,P = 0. 020）,APACHE II score（ OR = 1. 117,P ≤0. 001）,SCr level（ OR = 1. 006,P = 0. 020）,PaO2（ OR = 0. 993,P = 0. 006） and PaCO2（ OR = 0. 974,P = 0. 012）.COP of ICU duration days was 16. 5 days,APACHEII score was 22. 5,SCr level was 188. 0 μmol/L,and PaO2 level was 81. 5 mm Hg,PaCO2 level was 39. 5 mm Hg. Conclusion The CRRT risk factors for sepsis associated AKI patients in ICU include ICU duration days,APACHEII score,SCr level,PaO2 level and PaCO2 level. Patients with these abnormal factors may have higher risk receiving CRRT,we should pay more attention to modify survival.