神经重症患者发生急性肾损伤的危险因素分析

Study on risk factors of acute kidney injury in patients with critical neurological disease

目的探讨神经重症患者发生急性肾损伤(AKI)的危险因素及预后影响因素.方法回顾性分析2016年1月至2017年3月安徽医科大学附属省立医院(南区)重症医学科收治的207例神经重症患者的病例资料,按是否发生AKI将患者分为AKI组(40例)和非AKI组(167例);根据预后再将AKI患者分为存活组(14例)和死亡组(26例).收集患者发生AKI前的格拉斯哥昏迷评分(GCS)、急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、血糖、白细胞计数(WBC)、中心静脉压(CVP)、血钠、胱抑素C、尿素氮(BUN)以及使用甘油果糖和呋塞米的患者比例等.将单因素分析中差异有统计学意义的指标进行多因素logistic回归分析,筛选出影响神经重症患者发生AKI的危险因素和影响AKI患者预后的相关因素,并绘制受试者工作特征曲线(ROC),评估危险因素对神经重症患者发生AKI的预测效能.结果ICU神经重症患者AKI发生率为19.3%(40/207).AKI组院内病死率显著高于非AKI组〔65.0%(26/40)比22.2%(37/167),P<0.01〕.与非AKI组比较,AKI组GCS(分:4.44±1.65比5.39±1.62)、CVP〔cmH2O(1cmH2O=0.098 kPa):7.69±2.66比8.98±2.56〕均明显降低,APACHEⅡ(分:24.50±3.67比20.05±4.42)、血糖(mmol/L:12.33±6.53比9.33±3.26)、血钠(mmol/L:144.75±10.85比140.58±5.23)、WBC(×109/L:16.15±6.25比12.79±4.22)、胱抑素C(mg/L:1.27±0.74比0.74±0.26)、BUN(mmol/L:7.81±3.33比5.53±3.20)、男性比例〔77.5%(31/40)比59.9%(100/167)〕、合并低血压比例〔37.5%(15/40)比19.8%(33/167)〕、使用甘油果糖比例〔17.5%(7/40)比3.6%(6/167)〕以及使用呋塞米比例〔70.0%(28/40)比13.8%(23/167)〕均升高,上述指标比较差异均有统计学意义(均P<0.05).多因素logistic回归分析显示,高血糖〔优势比(OR)=1.201,95%可信区间(95%CI)=1.01~1.42,P<0.05〕和使用呋塞米治疗(OR=24.493,95%CI=4.92~120.36,P<0.01)是神经重症患者发生AKI的独立危险因素.ROC曲线分析显示,血糖对神经重症患者AKI有一定预测价值,ROC曲线下面积(AUC)为0.733,截断值为9.05 mmol/L时,敏感度为77.5%,特异度为62.6%.在AKI患者中,死亡组入院时GCS评分较存活组明显降低(分:3.77±0.87比5.50±2.03),血糖(mmol/L:16.51±9.10比10.09±2.89)和BUN(mmol/L:10.26±3.07比6.48±2.70〕较存活组明显升高(均P<0.05).结论AKI是神经重症患者的常见并发症,高血糖和使用呋塞米是神经重症患者发生AKI的独立危险因素;血糖对神经重症患者发生AKI有中等预测价值;GCS低、血糖及BUN升高的AKI患者死亡风险加大.

Objective To investigate the risk factors of acute kidney injury(AKI)occurring in patients with critical neurological disease,and the related factors affecting their prognosis.Methods The clinical data of 207 patients with critical neurological disease admitted to the Department of Critical Care Medicine of Anhui Provincial Hospital Affiliated to Anhui Medical University(South District)from January 2016 to March 2017 were analyzed retrospectively,they were assigned into an AKI group(40 cases)and a non-AKl group(167 cases),and according to the prognosis,the patients with AKI were subdivided into a survival subgroup(14 cases)and a death subgroup(26 cases).Clinical data of Glasgow coma score(GCS),acute physiology and chronic health evaluation II(APACHE II),blood glucose,white blood cell count(WBC),central venous pressure(CVP),blood sodium,cystatin C,urea nitrogen(BUN)etc.index levels and the proportions of patients using glycerin fnictose and furosemide before occurrence of AKI were collected.The indexes with statistical significant difierences found in the univariate analysis were analyzed by multivariate logistic regression analysis to screen out the risk factors influencing the occurrence of AKI and the factors related to the prognosis of the AKI patients;the receiver operating characteristic curve(ROC)was drawn to assess the predictive value of risk factors in patients with severe neurological disease to develop AKI.Results The incidence of AKI was 19.3%(40/207)in the patients with critical neurological disease.The hospital mortality in AKI group was significantly higher than that in the non-AKI group[65.0%(26/40)vs.22.2%(37/167),P<0.01].Compared with non-AKI group,GCS(4.44±1.65 vs.5.39±1.62),CVP[cmH20(1 cmH2O=0.098 kPa):7.69±2.66 vs.8.98±2.56]were obviously lower in AKI group at admission,APACHE K(24.50±3.67 vs.20.05±4.42),blood glucose(mmol/L:12.33±6.53 vs.9.33±3.26),serum sodium(mmol/L:144.75±10.85 vs.140.58±5.23),WBC(×10^9/L:16.15±6.25 vs.12.79±4.22),Cystatin C(mg/L:1.27±0.74 vs.0.74±0.26)and BUN(mmol/L:7.81±3.33 vs.5.53±3.20)and proportion of male[77.5%(31/40)vs.59.9%(100/167)],patients with the comorbidity of hypotension[37.5%(15/40)vs.19.8%(33/167)],use of glycerin fructose 117.5%(17/40)vs.3.6%(6/167)],or use of furosemide[70.0%(28/40)vs.13.8%(6/167)]were significantly increased in AKl group,there was a statistically significant difference between the above two groups(all P<0.05).Multivariate logistic regression analysis showed that the hyperglycemia[odds ratio(OR)=1.201,95%confidence interval(95%CI)=1.01-1.42.P<0.05]and use of furosemide for treatment(OR=24.493,95%CI=4.92-120.36,P<0.01)were the independent risk factors for occurrence of A KI in critical neurological patients.ROC curve analysis showed that blood sugar had certain predictive value of developing AKI in patients with critical neurological disease,the area under the ROC curve(AUC)of blood glucose was 0.733,when the optimal cut-off value of blood glucose was 9.05 mmol/L,the sensitivity was 77.5%and the specificity was 62.6%.Compared with the survival subgroup in the patients with AKl,the GCS at admission in death subgroup was significantly lower(3.77±0.87 vs.5.50±2.03),but their levels of blood glucose(mmol/L:16.51±9.10 vs.10.09±2.89)and BUN(mmol/L:10.26±3.07 vs.6.48±2.70)were obviously higher than those in the survival subgroup(all P<0.05).Conclusion AKl is one of the common complications in patients with critical neurological disease,hyperglycemia and the use of furosemide are the independent risk factors of occurrenee of AKl in such patients;the blood glucose has moderate predictive value;and lower GCS,higher glucose and BUN levels in AKl patients may enhance their risk of death.