危重孕产妇妊娠相关AKI发生与死亡的危险因素分析:一项单中心回顾性研究

Incidence and mortality risk factors of acute kidney injury in critical ill pregnancies:a single center retrospective analysis

目的探讨重症医学科(ICU)患者妊娠相关急性肾损伤(PR-AKI)发生及死亡相关危险因素.方法回顾性分析2012年1月1日至2016年12月31日入住山东大学附属省立医院ICU的危重孕产妇临床资料.采用改善全球肾脏病预后组织(KDIGO)提出的急性肾损伤(AKI)诊断及分期标准将ICU孕产妇分为PR-AKI组和非PR-AKI组,比较两组患者的临床特征、实验室数据;分析影响PR-AKI发生和住院死亡的危险因素;绘制受试者工作特征曲线(ROC),评估各危险因素对PR-AKI患者住院死亡的预测价值.结果①共219例ICU孕产妇纳入分析,其中85例发生PR-AKI,发生率为38.8%,AKI 1、2、3期分别占29.4%、27.1%和43.5%.②219例入住ICU危重孕产妇死亡19例,总体住院病死率为8.7%,其中PR-AKI组住院病死率明显高于非PR-AKI组(16.5%比3.7%,P=0.003);PR-AKI组病死率随AKI分期加重而升高(AKI 1期为4.0%,AKI 2期为4.3%,AKI 3期为32.4%).③妊娠期急性脂肪肝(AFLP)和血乳酸(Lac)增高是ICU孕产妇发生PR-AKI的独立危险因素〔AFLP:优势比(OR)=6.081,95%可信区间(95%CI)为1.587~23.308,P=0.008;高Lac:OR=1.460,95%CI为1.078~1.977,P=0.014〕.④年龄、Lac、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)是ICU中PR-AKI患者住院死亡的独立危险因素(年龄:OR=1.130,95%CI为1.022~1.249,P=0.017;Lac:OR=1.198,95%CI为1.009~2.421,P=0.039;APACHEⅡ:OR=1.211,95%CI为1.102~1.330,P<0.001;SOFA:OR=1.411,95%CI为1.193~1.669,P<0.001).⑤年龄、Lac、APACHEⅡ及SOFA评分均对ICU中PR-AKI患者住院死亡风险有较好的预测价值,最佳截断值分别为29岁、3.8 mmol/L、16分和8分〔ROC曲线下面积(AUC)分别为0.751、0.757、0.892和0.919,均P<0.01〕.结论ICU危重孕产妇PR-AKI发生率较高,可明显增加患者住院病死率;年龄、Lac、APACHEⅡ和SOFA评分增高是ICU中PR-AKI患者住院死亡的独立危险因素,且均对患者预后具有良好的预测价值.

Objective To evaluate the incidence and mortality risk factors of pregnancy-related acute kidney injury(PR-AKI)in intensive care unit(ICU).Methods A retrospective analysis was conducted.Critically ill pregnancies admitted to ICU of Shandong University Affiliated Provincial Hospital from January 1st,2012 to December 31st,2016 were enrolled.Based on the Kidney Disease:Improving Global Outcomes(KDIGO)-acute kidney injury(AKI)criteria,patients were divided into two groups:PR-AKI group and non-PR-AKI group.Clinical characteristics and laboratory data of two groups were compared.Risk factors of incidence and mortality of PR-AKI patients were analyzed,and the receiver operating characteristic(ROC)curve was drawn to evaluate the value of these risk factors in predicting mortality of PR-AKI patients in ICU.Results①A total of 219 pregnancies in ICU were included in the analysis,85 cases(38.8%)were diagnosed with PR-AKI,with 29.4%in AKI stage 1,27.1%in AKI stage 2 and 43.5%in AKI stage 3.②Nineteen of 219 critically ill pregnancies died in ICU,the total ICU mortality was 8.7%.The mortality of PR-AKI group was higher than non-PR-AKI group(16.5%vs.3.7%,P=0.003).The mortality was worsened with increasing severity of AKI(4.0%for AKI stage 1,4.3%for AKI stage 2,32.4%for AKI stage 3).③Acute fatty liver of pregnancy(AFLP)and lactate(Lac)were the independent risk factors for PR-AKI[AFLP:odds ratio(OR)=6.081,95%confidence interval(95%CI)was 1.587-23.308,P=0.008;Lac:OR=1.460,95%CI was 1.078-1.977,P=0.014].④Age,Lac,acute physiology and chronic health evaluationⅡ(APACHEⅡ)and sequential organ failure assessment(SOFA)were the independent risk factors associated with the mortality of PR-AKI patients in ICU(age:OR=1.130,95%CI was 1.022-1.249,P=0.017;Lac:OR=1.198,95%CI was 1.009-2.421,P=0.039;APACHEⅡ:OR=1.211,95%CI was 1.102-1.330,P<0.001;SOFA:OR=1.411,95%CI was 1.193-1.669,P<0.001).⑤ROC curve analysis showed that age,Lac,APACHEⅡscore and SOFA score all had good predictive values for in-hospital mortality among PR-AKI patients in ICU,the cut-off value was 29 years old,3.8 mmol/L,16 and 8,respectively,and the AUC was 0.751,0.757,0.892 and 0.919,respectively(all P<0.01).Conclusions The incidence and mortality of PR-AKI of critically ill pregnancies in ICU are high.Increased age,Lac,APACHEⅡscore and SOFA score are independent risk factors associated with the mortality of PR-AKI patients in ICU,and have good predictive values for prognosis.