改善全球肾脏疾病预后组织急性肾损伤不同诊断标准对高龄老年住院患者90天预后的影响

Effect of Kidney Disease Improving Global Outcomes diagnosis criteria for acute kidney injury on 90-day prognosis in very old patients

目的比较改善全球肾脏疾病预后组织(KDIGO)指南中急性肾损伤(AKI)不同诊断标准对老年住院患者短期预后的影响。方法收集2007年1月1日至2015年12月31日在解放军总医院老年病房住院的≥75岁AKI患者的病历资料652例,中位年龄87(84~91)岁。根据诊断窗将所有患者分为2组:48 h诊断窗组(n=334)和7 d诊断窗组(n=318)。根据患者AKI发生后90 d内的生存情况分为2组:生存组(n=433)和死亡组(n=219)。对比各组患者的一般情况和临床特征。采用SPSS 17.0软件进行统计分析。根据数据类型,组间比较采用t检验、Mann-Whitney U或χ2检验。对可能影响生存时间的因素进行Cox回归分析。采用Kaplan-Meier分析估算累计生存率。结果 652例住院患者根据KDIGO分期标准,AKI 1期308(47.2%)例,2期164(25.2%)例,3期180(27.6%)例。利用48 h诊断窗做出AKI诊断的患者占51.2%(334/652),利用基线值7 d诊断窗做出AKI诊断的患者占48.8%(318/652)。48 h诊断窗组和7 d诊断窗组患者的90 d病死率分别为42.5%和24.2%。Kaplan-Meier生存曲线比较显示,采用7 d诊断窗患者的90 d生存状况要显著好于采用48 h诊断窗者(P<0.001);随着发生AKI时间的增加,患者90 d病死率显著减少(P<0.001)。Cox多因素分析显示,低体质量指数(HR=0.928,95%CI:0.886~0.973;P=0.002)、低平均动脉压(HR=0.969,95%CI:0.959~0.979;P<0.001)、低血清前白蛋白(HR=0.948,95%CI:0.920~0.977;P<0.001)、低白蛋白(HR=0.962,95%CI:0.930~0.995;P=0.025)、感染(HR=1.374,95%CI:1.027~1.840;P=0.033)、少尿(HR=2.069,95%CI:1.341~3.192;P=0.001)、血尿素氮增高(HR=1.027,95%CI:1.015~1.038;P<0.001)、高镁(HR=2.485,95%CI:1.351~4.570;P=0.003)、更高的AKI分期(2期:HR=4.035,95%CI 2.381~6.837,P<0.001;3期:HR=7.184,95%CI 4.301~11.997,P<0.001)、AKI诊断时间≤48 h(HR=1.818,95%CI:1.256~2.631;P=0.002)是影响住院老年AKI患者90 d死亡的独立危险因素。结论 48 h诊断窗的AKI患者90 d病死率高于7 d诊断窗的AKI患者,AKI诊断时间≤48 h是影响住院老年AKI患者90 d死亡的独立危险因素。

Objective To compare the effect of different diagnostic criteria for acute kidney injury （AKI） from Kidney Disease Improving Global Outcomes （KDIGO） on short-term prognosis in the very elderly inpatients. Methods Clinical data of 652 AKI patients （≥75-year-old, median age 87, ranging from 84 to 91） admitted in our department between January 2007 and December 2015 were collected and retrospectively analyzed in this study. According to the diagnostic window, they were divided into 48-hour diagnostic window group （n=334） and 7-day diagnostic window group （n=318）. These patients were also divided into survival （n=433） and death groups （n=219） by their outcomes within 90 d after AKI. Their general conditions and clinical characteristics were compared between the 2 groups. SPSS statistics 19.0 was used to perform the statistical analysis. Student’[KG-＊3]s t test, Mann-whitney U test or Chi-square test was used for comparison of different data types between groups. Prognostic survival factors were identified using Cox regression analysis. Kaplan-Meier survival analysis was employed for accumulative survival rate. Results For these 652 enrolled patients, 308 （47.2%） were stratified into stage 1 AKI, 164（25.2%） into stage 2 AKI, and 180（27.6%） into stage 3 AKI according to KDIGO clinical practice guideline. While, 334 cases （51.2%） were diagnosed as AKI by 48-hour diagnostic window, and 318 cases （48.8%） by 7-day diagnostic window. The 90-day mortality was 42.5% in the patients of 48-hour diagnostic window group and 24.2% in those of 7-day diagnostic window group. Kaplan-Meier survival curves showed the 90-day mortality was better in the 7-day diagnostic window group than in the 48-hour diagnostic window group （P〈0.001）. With the increase of time for AKI occurrence, the 90-day mortality was significantly decreased （P〈0.001）. Multivariate analysis by the Cox model revealed that low body mass index （HR=0.928, 95%CI：0.886-0.973; P=0.002）, low mean arterial pressure （HR=0.969,5%CI：0.959-0.979; P〈0.001）, low serum prealbumin level （HR=0.948,5%CI：0.920-0.977; P〈0.001）, low albumin level （HR=0.962, 95%CI：0.930-0.995; P=0.025）, infection （HR=1.374,5%CI：1.027-1.840; P=0.033）, oliguria （HR=2.069, 95%CI：1.341-3.192; P=0.001）, high blood urea nitrogen level （HR=1.027,5%CI：1.015-1.038; P〈0.001） and magnesium level （HR=2.485,5%CI：1.351-4.570; P=0.003）, more severe AKI stages （stage 2：HR=4.035, 95%CI：2.381-6.837, P〈0.001; stage 3：HR=7.184; 95%CI：4.301-11.997, P〈0.001）, and ≤48-hour window for AKI diagnosis （HR=1.818,5%CI：1.256-2.631; P=0.002） were independent risk factors for 90-day mortality in hospitalized elderly AKI patients. Conclusion The 90-day mortality is higher in 48-hour window AKI than in 7-day window AKI in the very old patients. ≤48-hour window for AKI diagnosis is an independent factor for 90-day mortality for the elderly.