部分临床指标对CRRT相关低血压发生的预测价值

Value of some clinical parameters in predicting continuous renal replacement therapy-related hypotension

目的筛选具有预测肾功能衰竭患者行连续性肾脏替代治疗(CRRT)时相关低血压发生的临床指标。方法采用回顾性研究方法,选择2012年7月1日至2019年6月30日在青岛市市立医院进行CRRT治疗的肾功能衰竭患者。收集患者性别、年龄、体重,CRRT治疗前的收缩压(SBP)、舒张压(DBP)、平均动脉压(MAP)、中心静脉压(CVP)、心率、血常规、血生化、B型钠尿肽(BNP)、心胸比、左室射血分数(LVEF),CRRT治疗时间、血流速度、置换剂量、治疗结束后的净超滤量等指标,计算超滤速率以及30 d预后。将发生CRRT相关低血压和超滤为零的患者纳入超滤不耐受组,其余纳入正常超滤组,比较两组患者各指标的差异;运用受试者工作特征曲线(ROC)分析各指标预测患者CRRT相关低血压发生的价值。结果正常超滤组(98例)与超滤不耐受组(13例)患者年龄、BNP、CVP、CRRT时间、净超滤量和超滤速率比较差异均有统计学意义〔年龄(岁):66.21±12.21比74.54±5.93,BNP(ng/L):1617.57(755.00,2296.25)比398.95(76.80,703.00),CVP(cmH2O,1 cmH2O=0.098 kPa):14.99±2.28比12.60±1.14,CRRT时间(h):23.71±11.48比14.51±8.99,净超滤量(mL):3120.98(1863.75,3515.00)比793.85(0,1125.00),超滤速率(mL/h):133.44(98.72,156.64)比68.47(0,105.21),均P<0.05〕。ROC曲线分析显示,年龄、BNP、CVP、CRRT时间、净超滤量和超滤速率对CRRT相关低血压发生均具有较好的预测价值〔ROC曲线下面积(AUC)和95%可信区间(95%CI):年龄为0.734(0.626~0.842),BNP为0.868(0.776~0.960),CVP为0.846(0.757~0.935),CRRT时间为0.746(0.595~0.897),净超滤量为0.926(0.845~1.000),超滤速率为0.794(0.620~0.969)〕。此外,根据超滤速率截断值分组进一步比较显示,超滤速率≥99.50 mL/h组与<99.50 mL/h组在BNP、CVP和净超滤量方面差异有统计学意义;ROC曲线分析显示,BNP和CVP对设置超滤速率≥99.50 mL/h发生CRRT相关低血压具有较好的预测价值,其AUC和95%CI分别为0.716(0.604~0.828)、0.749(0.651~0.847),敏感度分别为70.0%、78.8%,特异度分别为35.5%、45.2%。结论CRRT治疗前,年龄、BNP和CVP对于肾功能衰竭患者是否易于发生CRRT相关低血压具有较好的预测价值。

Objective To screen the clinical parameters in predicting continuous renal replacement therapy(CRRT)-related hypotension in the patients with renal failure.Methods A retrospective analysis was conducted.Patients with renal failure received CRRT admitted to Qingdao Municipal Hospital from July 1st,2012 to June 30th 2019 were enrolled.Clinical data was recorded for the patients,including gender,age,weight,parameters before CRRT[systolic pressure(SBP),diastolic pressure(DBP),mean arterial pressure(MAP),central venous pressure(CVP),heart rate,blood routine examination,blood biochemistry,B-type natriuretic peptide(BNP),cardiothoracic ratio,left ventricular ejection fraction(LVEF)],CRRT duration,blood flow velocity,replacement fluid volume,net ultrafiltration volume,ultrafiltration rate and 30-day prognosis.The patients who had CRRT-related hypotension or whose net ultrafiltration was zero were enrolled as intolerance ultrafiltration group.Others were enrolled in normal ultrafiltration group.The parameters of the patients in the two groups were compared,and their predictive values in CRRT-related hypotension were evaluated by receiver operating characteristic(ROC)curve analysis.Results There was significant difference in age,BNP,CVP,CRRT duration,net ultrafiltration volume,and ultrafiltration rate between the normal ultrafiltration group(n 98)and intolerance ultrafiltration group[n 13;age(years old):66.21±12.21 vs.74.54±5.93,BNP(ng/L):1617.57(755.00,2296.25)vs.398.95(76.80,703.00),CVP(cmH2O,1 cmH2O=0.098 kPa):14.99±2.28 vs.12.60±1.14,CRRT duration(hours):23.71±11.48 vs.14.51±8.99,net ultrafiltration volume(mL):3120.98(1863.75,3515.00)vs.793.85(0,1125.00),ultrafiltration rate(mL/h):133.44(98.72,156.64)vs.68.47(0,105.21),all P<0.05].ROC curve analysis showed that age,BNP,CVP,CRRT duration,net ultrafiltration volume and ultrafiltration rate had good predictive value for the CRRT-related hypotension[the area under ROC curve(AUC)and 95%confidence interval(95%CI):age was 0.734(0.626-0.842),BNP was 0.868(0.776-0.960),CVP was 0.846(0.757-0.935),CRRT duration was 0.746(0.595-0.897),net ultrafiltration volume was 0.926(0.845-1.000),and ultrafiltration rate was 0.794(0.620-0.969),respectively].Furthermore,according to the cut-off point of ultrafiltration rate,the patients were divided into≥99.50 mL/h group and<99.50 mL/h group.There were statistical differences in BNP,CVP and net ultrafiltration volume between the two groups.ROC curve analysis showed that BNP and CVP had good prediction value for hypotension when ultrafiltration rate exceeds≥99.50 mL/h.The AUC(95%CI)of BNP and CVP were 0.716(0.604-0.828)and 0.749(0.651-0.847),the sensitivity was 70.0%,78.8%,and the specificity was 35.5%,45.2%,respectively.Conclusion The values of age,BNP and CVP are more useful than other parameters in predicting CRRT-related hypotension before the start.