急性肾损伤进展至慢性肾脏病的临床特征和危险因素——前瞻性、观察性队列研究

Characteristics and risk factors of acute kidney injury progressed to chronic kidney disease:a prospective,observational cohort study

目的前瞻性探讨和分析急性肾损伤(acute kidney injury,AKI)发生后进展至慢性肾脏病(chronic kidney disease,CKD)的临床表型特征和相关危险因素,初步建立AKI进展至CKD的临床风险预测模型,并评估其对AKI进展至CKD的预测效能。方法本研究为前瞻性、观察性队列研究,纳入2015年4月至2019年12月因AKI在南方医院肾内科住院且既往无CKD[估算肾小球滤过率(eGFR)<60 ml·min^-1·(1.73 m^2)^-1]的患者。全部患者出院后随访至AKI发生后90 d,检测AKI发生90 d后的血肌酐值(≥2次检测),用血肌酐均值和EPI-CKD 2009公式计算eGFR。以AKI发生后90 d内新发CKD[eGFR<60 ml·min^-1·(1.73 m^2)^-1]为研究终点,比较AKI进展至CKD和AKI未进展至CKD两组患者的临床特征,包括人口学特点、慢性并发症比例、基线肾功能、AKI严重程度、AKI时是否接受透析和其他实验室指标。通过多因素Logistic回归分析模型分析AKI进展至CKD的独立临床危险因素;最后,初步建立临床危险因素模型,用受试者工作特征曲线下面积(AUC)评价临床模型对AKI进展至CKD的预测效能。结果共168例AKI患者被纳入本研究,男91例,女77例,年龄(44.0±18.4)岁;其中64例(38.1%)在AKI发生后90 d内新发CKD(AKI进展至CKD)。与AKI未进展至CKD者相比,AKI进展至CKD组患者年龄大、基线eGFR和血红蛋白水平低、合并高血压比例高、AKI时接受透析比例高、出院时的血肌酐水平也较高(均P<0.05)。两组间其他指标如合并糖尿病比例、血管紧张素系统抑制剂使用比例、尿蛋白水平及其他实验室指标差异无统计学意义。多因素Logistic回归分析显示,AKI时接受透析(OR=2.516,95%CI 1.251~5.060,P=0.010)、合并高血压(OR=2.446,95%CI 1.124~5.324,P=0.024)、低基线eGFR(OR=0.975,95%CI 0.950~0.999,P=0.043)是AKI进展至CKD的独立危险因素。初步分析显示,由年龄、AKI时接受透析、合并高血压、低基线eGFR建立的临床模型对AKI进展至CKD的预测效能为中等(AUC=0.712,95%CI 0.634~0.790)。结论AKI住院人群是未来新发CKD的高危人群,由全身疾病状态和AKI严重程度组成的综合临床风险预测模型有助于筛查AKI进展至CKD的高危患者,但仍需进一步寻找能提高AKI慢性化风险预测效能的临床因素和生物标志物。

Objective To prospectively investigate the characteristics of acute kidney injury(AKI)that progressed to chronic kidney disease(CKD)(AKI to CKD)in patients hospitalized for AKI,determine the risk factors of AKI to CKD,and preliminarily evaluate the performance of clinical risk factor model for predicting AKI to CKD.Methods This was a prospective,observational cohort study.Patients hospitalized for AKI and without a prior CKD[estimated glomerular filtration rate(eGFR)<60 ml·min^-1·(1.73 m^2)^-1]were enrolled in Nanfang Hospital of Southern Medical University from April 2015 to December 2019.Survived patients were followed 90 days after AKI and the renal function 90 days post AKI was determined.The primary endpoint was AKI to CKD,defined as new-onset CKD[eGFR<60 ml·min^-1·(1.73 m^2)^-1 90 days post AKI].According to AKI progressed to CKD or not,AKI patients were divided into two groups(with or without AKI to CKD).The baseline clinical data of demographics,comorbidities,baseline renal function,AKI severity,receiving hemodialysis or not,and other lab parameters were compared between two groups.The logistic regression model was used to analyze the risk factors of AKI to CKD.Finally,receiver operator characteristic(ROC)curve was drawn to evaluate the performance of clinical risk factor model for predicting AKI to CKD.Results A total of 168 patients with AKI was enrolled in this study[male,n=91;female,n=77;age(44.0±18.4)years],in which 64 patients(38.1%)developed new-onset CKD 90 days post AKI and 104 patients(61.9%)did not.Compared to those without AKI to CKD,patients with AKI to CKD were older,and had a higher proportion of hypertension,lower levels of eGFR and hemoglobin,higher proportion of receiving hemodialysis,and higher level of discharged serum creatinine(all P<0.05).There was no significant difference in the proportion of diabetes and use of RAS inhibitors,urine protein level,and other lab parameters between two groups.Multivariate logistic regression analysis shows that receiving hemodialysis(OR=2.516,95%CI 1.251-5.060,P=0.010),hypertension(OR=2.446,95%CI 1.124-5.324,P=0.024),and lower baseline eGFR(OR=0.975,95%CI 0.950-0.999,P=0.043)were the independent risk factors for AKI to CKD.The clinical risk factor model including age,receiving hemodialysis,hypertension,and baseline eGFR produced moderate performance for predicting AKI to CKD,with the area under ROC curve of 0.712,95%CI 0.634-0.790.Conclusions AKI survivors are at high risk for developing CKD.Receiving hemodialysis,hypertension,and lower baseline eGFR are independent risk factors for predicting AKI to CKD.More studies are needed to improve the performance of clinical risk factor model for early detecting high risk patients who will develop AKI to CKD.