ICU脓毒症合并急性肾损伤患者CRRT后死亡危险因素:一项多中心观察研究数据的二次分析

Risk factors for mortality in intensive care unit patients with sepsis combined with acute kidney injury after continuous renal replacement therapy: secondary analysis of the data from a multicenter observational study

目的分析重症加强治疗病房(ICU)脓毒症合并急性肾损伤(AKI)患者进行连续性肾脏替代治疗(CRRT)的死亡危险因素。方法对BAKIT研究(一项对北京28家医院30个ICU患者AKI流行病学进行的前瞻性观察性研究)中2012年3月1日至8月31日收集的脓毒症合并AKI并接受CRRT治疗患者的数据进行二次分析。收集患者的人口学资料、临床和实验室数据,主要包括性别、年龄、病例来源、体重指数(BMI)、血压、ICU住院时间、合并症、伴随的非肾脏器官情况、药物应用情况,CRRT、机械通气和血管活性药物等干预措施,以入ICU 24 h内指标最差值计算急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)和序贯器官衰竭评分(SOFA)。观察终点为转出ICU(存活)或死亡。对所有测试因素进行单因素分析,再对单因素分析中差异有统计学意义的参数进行多因素Logistic回归分析,筛选影响ICU脓毒症合并AKI患者进行CRRT的死亡危险因素。结果共纳入189例患者,其中死亡103例,病死率为54.50%。与存活组比较,死亡组患者年龄高〔岁:77(67,83)比58(39,73)〕,因呼吸系统疾病入ICU的比例较高(55.40%比38.37%),存在心功能Ⅳ级、高血压、冠心病、慢性肾脏病(伴肾功能不全)等合并症的比例高(分别为20.39%比3.49%,53.40%比34.88%,40.78%比10.47%,20.39%比9.30%),ICU住院时间长〔d:8(5,19)比13(7,22)〕,APACHEⅡ及SOFA评分高(分:27.53±8.59比22.73±8.36,12.22±4.00比9.51±4.49),平均动脉压(MAP)最低值低〔mmHg(1 mmHg=0.133 kPa):65.36±19.52比71.60±17.92〕,有创机械通气比例高(80.58%比65.12%),因高钾血症及严重代谢性酸中毒而行CRRT治疗的比例高(28.16%比9.30%,63.11%比22.09%),入ICU至启动CRRT的时间长〔d:1(0,5)比1(0,2)〕,差异均有统计学意义(均P<0.05)。Logistic回归分析显示,年龄、APACHEⅡ、SOFA、MAP、心功能Ⅳ级、冠心病、高钾血症为ICU脓毒症合并AKI进行CRRT治疗患者死亡的危险因素,其中年龄、APACHEⅡ、SOFA及心功能Ⅳ级为其独立危险因素〔年龄:优势比(OR)=1.054,95%可信区间(95%CI)=1.032~1.077,P<0.001;APACHEⅡ:OR=1.061,95%CI=1.021~1.102,P=0.034;SOFA:OR=1.078,95%CI=1.033~1.116,P=0.042;心功能Ⅳ级:OR=3.357,95%CI=0.884~12.747,P=0.045〕。结论年龄、APACHEⅡ、SOFA及心功能Ⅳ级为ICU脓毒症合并AKI患者CRRT治疗后死亡的独立危险因素。

Objective To analyze the risk factors of death in intensive care unit (ICU) patients with sepsis and acute kidney injury (AKI) undergoing continuous renal replacement therapy (CRRT). Methods The data of patients with sepsis complicated with AKI who received CRRT treatment from March 1st to August 31st in 2012 in BAKIT study (a prospective observational study of AKI epidemiology in 30 ICUs of 28 hospitals in Beijing) were re-analyzed. The demographic data, clinical and laboratory data of patients were collected, including gender, age, case source, body mass index (BMI), blood pressure, the length of ICU stay, complications, other organs' function, drug use, CRRT, mechanical ventilation and vasoactive drugs. Acute physiology and chronic health evaluation Ⅱ(APACHEⅡ) and sequential organ failure score (SOFA) were calculated by the worst value of the index within 24 hours of entry into ICU. The end point of observation was to ICU mortality. All test factors were analyzed by single factor analysis, and then multivariate Logistic regression analysis was carried out for the parameters with statistical significance in single factor analysis. Risk factors affecting CRRT in ICU sepsis patients with AKI were screened. Results A total of 189 patients were enrolled, 103 of whom died, with a mortality rate of 54.50%. Compared with the survival group, the death group had an older age [years old: 77(67, 83) vs. 58 (39, 73)], a higher proportion of ICU entry due to respiratory diseases (55.40% vs. 38.37%), a higher proportion of complications such as grade Ⅳ of cardiac function, hypertension, coronary heart disease, chronic kidney disease (with renal insufficiency;20.39% vs. 3.49%, 53.40% vs. 34.88%, 40.78% vs.10.47%, 20.39% vs. 9.30%, respectively), a longer the length of ICU stay [days: 8 (5, 19) vs. 13 (7, 22)], a higher APACHEⅡ and SOFA scores (27.53±8.59 vs. 22.73±8.36, 12.22±4.00 vs. 9.51±4.49), a lower mean arterial pressure (MAP) valley value [mmHg (1 mmHg = 0.133kPa): 65.36±19.52 vs. 71.60±17.92], a higher proportion of invasive mechanical ventilation (80.58% vs. 65.12%), high proportion of CRRT treatment due to hyperkalemia and severe metabolic acidosis (28.16% vs. 9.30%, 63.11% vs. 22.09%), and the time from ICU entry to CRRT initiation was longer [days: 1 (0, 5) vs. 1 (0, 2)], which differences were statistically significant (all P < 0.05). Logistic regression analysis showed that age, APACHEⅡ, SOFA, MAP, grade Ⅳof cardiac function, coronary heart disease and hyperkalemia were risk factors for death in ICU sepsis patients with AKI treated by CRRT. Age, APACHEⅡ, SOFA and grade Ⅳof cardiac function were independent risk factors [age: odds ratio (OR)= 1.054, 95% confidence interval (95%CI)= 1.032-1.077, P < 0.001;APACHEⅡ: OR = 1.061, 95%CI = 1.021-1.102, P = 0.034;SOFA: OR = 1.078, 95%CI = 1.033-1.116, P = 0.042;grade Ⅳof cardiac function: OR = 3.357, 95%CI = 0.884-12.747, P = 0.045]. Conclusion Age, APACHEⅡ, SOAF and gradeⅣof cardiac function were independent risk factors for death in ICU sepsis patients with AKI treated with CRRT.