连续性肾脏替代治疗介入时机对重症急性肾损伤患者预后影响

Effect of timing of continuous renal replacement therapy intervention on prognosis of patients with severe acute kidney injury

目的分析重症急性肾损伤(AKI)行连续性肾脏替代治疗(CRRT)患者临床特点,探讨CRRT介入时机对重症AKI患者预后影响。方法回顾性分析2009年1月1日至2015年12月31日在安徽医科大学第二附属医院重症医学科明确诊断AKI行CRRT患者141例,其中男性89例,女性52例;年龄3~88岁,平均年龄53.93岁。根据改善全球肾脏病预后组织(KDIGO)指南分KDIGO 1、2期和KDIGO 3期两组,比较两组患者一般人口学特征、实验室检查、疾病严重程度及预后情况,并对患者28 d生存率进行Logistic回归分析,从而得出影响重症AKI患者28 d存活率的危险因素。结果基线资料:KDIGO 1期18例,KDIGO 2期32例,KDIGO 3期91例;KDIGO 1、2期血肌酐、尿素氮、尿酸明显低于KDIGO 3期(P<0.001),其余生物化学指标两组间未见明显差异(P>0.05)。两组患者总住院日、重症监护病房(ICU)住院日、合并症(高血压、糖尿病、冠心病、慢性肾脏病)无明显差异(P>0.05)。引起重症AKI诱因组成:脓毒症54例(占38.3%),心脏术后25例(占17.7%),失血性休克22例(占15.6%),为引起AKI诱因的前3位;诱因为心脏术后的KDIGO 1、2期患者明显高于KDIGO 3期(P<0.001)。严重程度和预后比较:KDIGO 1、2期序贯脏器衰竭评估(SOFA)评分、急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分低于KDIGO 3期,差异有统计学意义(P<0.05);KDIGO 1、2期28 d生存率(70.0%)明显高于KDIGO 3期(46.1%),差异有统计学意义(P<0.01)。经二分类Logistic回归分析,年龄、是否机械通气、白细胞、血肌酐、白蛋白与生存率无关;高SOFA评分、高APACHEⅡ评分、KDIGO 3期为28 d存活率的独立危险因素;女性、ICU入住时间增加是28 d存活率的保护因素。结论基于KDIGO分期的早期CRRT,有望改善重症AKI患者的预后。

Objective To analyze the clinical characteristics of patients with severe acute kidney injury(AKI)performed continuous renal replacement therapy(CRRT),and investigate the effect of CRRT intervention timing on the prognosis of severe AKI patients.Methods From January 1 in 2009 to December 31 in 2015,141 patients with AKI performed CRRT were enrolled,which included 89 males and 52 females,aged 3-88 years old with mean age of 53.93 years old.According to guideline of Kidney Disease:Improving Global Outcomes(KDIGO),all of them were divided into KDIGO stage 1,2 group and KDIGO stage 3 group.The general demographic characteristics,laboratory examination,disease severity and prognosis between 2 groups were compared.The risk factor for 28-day survival rate in patients with severe AKI was obtained by Logistic regression analysis of 28-day survival rate.Results Baseline data:18 cases with KDIGO stage 1,32 of KDIGO stage 2,and 91 of KDIGO stage 3.The serum creatinine,urea nitrogen and uric acid of KDIGO stage 1,2 were significantly lower than those of KDIGO stage 3(P<0.001),and there were no significant difference in other biochemical indexes between 2 groups(P>0.05).There were no significant differences in hospitalization days,intensive care unit(ICU)days and complications(hypertension,diabetes,coronary heart disease,chronic kidney disease)between 2 groups(P>0.05).The inducement of severe AKI:sepsis in 54 cases(38.3%),cardiac surgery in 25(17.7%),and hemorrhagic shock in 22(15.6%).The number of patients whose cause were post cardiac surgery in KDIGO stage 1,2 was significantly higher than that of KDIGO stage 3(P<0.001).The comparison of severity and prognosis:the sequential organ failure assessment(SOFA)score,acute physiology and chronic health evaluation systemⅡ(APACHEⅡ)score in KDIGO stage 1,2 group assessment were lower than those in KDIGO stage 3 group,and difference was statistically significant(P<0.05);The 28-day survival rate in KDIGO stage 1,2 group(70.0%)was significantly higher than that in KDIGO stage 3 group(46.1%),and the difference was statistically significant(P<0.01).The binary Logistic regression analysis showed that age,mechanical ventilation,leukocyte,creatinine and albumin were not correlated with survival rate.High SOFA score and APACHEⅡscore,KDIGO stage 3 were independent risk factors for 28-day survival rate.Female,increased ICU days were the protective factors for 28-survival rate.Conclusion It is demonstrated that early initiation of CRRT based on KDIGO classification is expected to improve the prognosis of patients with severe AKI.