ICU急性肾损伤患者连续肾脏替代疗法临床分析

Clinical analysis of continuous renal replacement therapy in patients with acute kidney injury in ICU

目的探讨影响ICU中急性肾损伤患者行连续肾脏替代治疗(CRRT)后28 d存活率的危险因素。方法选择2008年1月1日至2013年12月31日在浙江大学医学院附属第一医院ICU住院并行CRRT治疗的急性肾损伤患者1 720例,共纳入1 165例患者。根据CRRT治疗后患者第28天的存活情况,将患者分为死亡组(689例)和存活组(476例),28 d病死率为59.14%(689/1 165)。比较两组患者的一般资料,并采用Logistic多元回归分析找出影响患者28 d存活率的危险因素。结果两组急性肾损伤患者CRRT治疗前年龄≥65岁、24 h尿量<400 m L、使用机械通气、应用升压药、平均动脉压<80 mm Hg、血小板计数<100×109/L、碳酸氢根<22 mmol/L、乳酸≥1.7 mmol/L、总胆红素≥100μmol/L、血肌酐<250μmol/L、血糖<3.9 mmol/L、急性病生理学和长期健康评价(APACHE)Ⅱ评分≥23分和简化急性生理学评分(SAPS)Ⅱ评分≥56分比较,差异均有统计学意义(χ2=10.376、11.596、85.674、103.017、86.318、41.626、9.862、86.269、30.228、28.691、13.664、212.194、232.712,P均<0.05)。Logistic回归分析结果显示,年龄≥65岁[OR=1.643,95%CI(1.214,2.224)]、平均动脉压<80 mm Hg[OR=1.932,95%CI(1.417,2.633)]、血小板计数<100×109/L[OR=1.968,95%CI(1.467,2.640)]、乳酸≥1.7 mmol/L[OR=1.665,95%CI(1.226,2.262)]、总胆红素≥100μmol/L[OR=2.263,95%CI(1.518,3.375)]、血肌酐<250μmol/L[OR=1.733,95%CI(1.269,2.366)]、血糖<3.9 mmol/L[OR=3.365,95%CI(1.282,8.831)]、APACHEⅡ评分≥23分[OR=3.233,95%CI(2.325,4.495)]和SAPSⅡ评分≥56分[OR=3.058,95%CI(2.170,4.309)]是影响ICU接受CRRT治疗的急性肾损伤患者28 d存活率的独立危险因素(P均<0.05)。结论年龄≥65岁、平均动脉压<80 mm Hg、血小板计数<100×109/L、乳酸≥1.7 mmol/L、总胆红素≥100μmol/L、血肌酐<250μmol/L、血糖<3.9 mmol/L、APACHEⅡ评分≥23分和SAPSⅡ评分≥56分是影响ICU接受CRRT治疗的急性肾损伤患者28 d存活率的独立危险因素。

Objective To investigate risk factors of the 28 d survival rate in patients with acute kidney injury after continuous renal replacement therapy （CRRT） in ICU. Methods A total of 1 720 patients with acute kidney injury treated with CRRT in ICU of the First Affiliated Hospital, College of Medicine, Zhejiang University from January 1, 2008 to December 31, 2013 were selected, and then 1 165 patients were analyzed. The patients were divided into the death group （689 cases） and the survival group （476 cases） according to the 28 d survival after CRRT treatment, and the 28 d mortality was 59.14% （689 / 1 165）. The general data of the two groups were compared, and the risk factors for the 28 d survival rate were identified by Logistic multivariate regression analysis. Results The age ≥ 65 years, the 24 h urine volume 〈 400 mL, the use of mechanical ventilation, the application of vasopressors, the mean arterial pressure 〈 80 mmHg, the platelet count 〈 100 × 109 / L, the bicarbonate radical 〈 22 mmol / L, the lactic acid 1.7 mmol / L, the total bilirubin ≥ 100 μmol / L, the serum creatinine 〈 250 μmol / L, the blood glucose 〈 3.9 mmol/L, the acute physiology and chronic health evaluation （APACHE） Ⅱ score ≥ 23 and the simplified acute physiology score （SAPS） Ⅱ ≥ 56 of patients with acute kidney injury before CRRT in these two groups were significantly different （X2= 10.376, 11.596, 85.674, 103.017, 86.318, 41.626, 9.862, 86.269, 30.228, 28.691, 13.664, 212.194, 232.712; all P〈 0.05）. Logistic regression analysis showed that the age ≥ 65 years [OR = 1.643, 95%CI （1.214, 2.224）], the mean arterial pressure 〈 80 mmHg [OR = 1.932, 95%CI （1.417, 2.633）], the platelet count 〈 100×109/L [OR = 1.968, 95%CI （1.467, 2.640）], the lactic acid≥ 1.7 mmol/L [OR = 1.665, 95%CI （1.226, 2.262）], the total bilirubin ≥ 100 μmol / L [OR = 2.263, 95%CI （1.518, 3.375）], the serum creatinine 〈 250 μmol / L [OR = 1.733, 95%C1 （1.269, 2.366）], the blood glucose 〈 3.9 mmol / L [OR = 3.365, 95%CI （1.282, 8.831）], the APACHEⅡscore ≥ 23 [OR = 3.233, 95%CI （2.325, 4.495）] and the SAPS Ⅱ score ≥ 56 [OR = 3.058, 95%CI （2.170, 4.309）] were the risk factors of 28 d survival rate in patients with acute kidney injury after CRRT in ICU （all P 〈 0.05）. Conclusion The age ≥ 65 years, the mean arterial pressure 〈 80 mmHg, the platelet count 〈 100 ×10^9 / L, the lactic acid t〉 1.7 mmol/L, the total bilirubin ≥100 μmol/L, the serum creatinine 〈 250 μmol/L, the blood glucose 〈 3.9 mmol / L the APACHE Ⅱ score≥ 23 and the SAPS Ⅱ score ≥ 56 were the risk factors of the 28 d survival rate in patients with acute kidney injury after CRRT in ICU.