ICU内脓毒性休克急性肾损伤患者肾功能恢复的影响因素分析

Analysis of factors influencing recovery of renal functions in septic shock patients in intensive care unit with acute kidney injury

目的:分析可能影响重症监护病房(ICU)脓毒性休克急性肾损伤(AKI)患者肾功能的多种因素,以期找到能预测患者肾功能改变的影响因素。方法:回顾性分析2017年1月至2019年6月武汉大学中南医院重症医学科收治脓毒性休克合并AKI患者的临床资料。收集患者一般资料、实验室及临床指标。按照肾功能水平变化将患者分为肾功能改善组和肾功能未改善组,对比两组患者各指标的差异,将单因素分析中差异有统计学意义的指标进行岭回归分析;采用受试者工作特征曲线(ROC)及其95%可信区间(95%CI)分析各影响因素对患者肾功能恢复的预测价值。结果:共纳入323例患者,其中肾功能改善组195例,肾功能未改善组128例。单因素分析显示,肾功能改善组与肾功能未改善组间急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、序贯器官衰竭评分(SOFA)、格拉斯哥昏迷评分(GCS)、心率(HR)、血清肌酐(SCr)、血尿素氮(BUN)、K+、白细胞计数(WBC)、中心静脉压最大值(CVP max)、中心静脉压最大值与最小值的差值(ΔCVP)、液体平衡量、血乳酸最大值(LAC max)、去甲肾上腺素最大输注速度(NE max)差异有统计学意义,将上述指标纳入岭回归分析显示,APACHEⅡ、SOFA、SCr、BUN、HR、WBC、液体平衡量、NE max是患者肾功能未改善的正向影响因素(t值分别为5.507、3.690、2.026、4.815、2.512、2.114、3.532、3.735,均P<0.05)。ROC曲线分析显示,APACHEⅡ、SOFA、BUN和NE max的联合指标对脓毒性休克AKI患者肾功能的预测价值最高,受试者工作特征曲线下面积(AUC)和95%CI为0.863(0.821~0.899),明显高于APACHEⅡ、SOFA、BUN、SCr、NE max等各单一指标〔AUC和95%CI:0.863(0.821~0.899)比0.755(0.705~0.801)、0.722(0.670~0.770)、0.738(0.686~0.785)、0.743(0.692~0.790)、0.748(0.697~0.794),均P<0.01〕以及APACHEⅡ、SOFA、SCr和NE max的联合指标〔AUC和95%CI:0.863(0.821~0.899)比0.825(0.799~0.865),P<0.01〕。结论:APACHEⅡ、SOFA、SCr、BUN、HR、WBC、液体平衡量、NE max是脓毒性休克AKI患者肾功能未改善的正向影响因素。联合APACHEⅡ、SOFA、BUN、NE max对患者肾功能是否改善具有较高的预测价值。

Objective To analyze multiple factors that may affect renal function in septic shock patients with acute kidney injury(AKI)in the intensive care unit(ICU),in order to find factors of predictive value for renal function change in those patients.Methods Septic patients with AKI admitted to department of critical care medicine of Wuhan University Zhongnan Hospital from January 2017 to June 2019 were enrolled,and the patients were divided into renal function improvement group and renal function non-improvement group according to their renal function change.Baseline,laboratory and clinical indicators of them were collected to conduct retrospective analysis.Comparing the difference of each index between the two groups,the statistically significant indexes in the univariate analysis were selected to perform ridge regression analysis.The receiver operating characteristic(ROC)curve and its 95%confidence interval(95%CI)were used to analyze the predictive value of each influencing factor on the recovery of renal function in patients.Results A total of 323 patients met the inclusion criteria,and 195 of them were divided into renal function improvement group while the other 128 of them into the renal function non-improvement group.Univariate analysis showed that,there was significantly difference in acute physiology and chronic health evaluationⅡ(APACHEⅡ),sequential organ failure assessment(SOFA),Glasgow coma score(GCS),heart rate(HR),serum creatinine(SCr),blood urea nitrogen(BUN),potassium(K+),white blood cell count(WBC),maximum central venous pressure(CVPmax),maximum-minimum central venous pressure distance(ΔCVP),fluid balance,maximum lactic acid(LACmax),and maximum norepinephrine infusion speed(NEmax)between the renal function improvement group and the renal function non-improvement group.Ridge regression analysis of those indexes found that APACHEⅡ,SOFA,SCr,BUN,HR,WBC,fluid balance,and NEmax were influential factors of non-improvement renal function(t values were 5.507,3.690,2.026,4.815,2.512,2.114,3.532,3.735,all P<0.05).ROC analysis found the predictive value combining the APACHEⅡ,SOFA,BUN,NEmax was the highest[the area under ROC curve(AUC)and 95%CI:0.863(0.821-0.899)],which had a higher AUC than any of APACHEⅡ,SOFA,BUN,SCr and NEmax[AUC and 95%CI:0.863(0.821-0.899)vs.0.755(0.705-0.801),0.722(0.670-0.770),0.738(0.686-0.785),0.743(0.692-0.790),0.748(0.697-0.794),all P<0.01],and so did it when compared to APACHEⅡ,SOFA,SCr and NEmax combination[AUC and 95%CI:0.863(0.821-0.899)vs.0.825(0.799-0.865),P<0.01].Conclusions APACHEⅡ,SOFA,SCr,BUN,HR,WBC,fluid balance,and NEmax are the positive influencing factors for patients without renal function improvement.The combination of APACHEⅡ,SOFA,BUN,and NEmax had a relatively high predictive value for renal function recovery.