ICU使用万古霉素的患者发生肾功能亢进的危险因素分析

Analysis of risk factors ofaugmented renalclearance incritically ill patients treated with vancomycin

目的:探讨ICU使用万古霉素的患者发生肾功能亢进(ARC)的危险因素。方法:回顾性分析2016年1月—2019年2月在某院重症医学科(ICU)接受万古霉素常规剂量1 g q12 h治疗的患者。根据患者是否存在ARC进行分组,ARC定义为患者肌酐清除率(CrCl)≥130 mL·(min·1.73 m2)-1,采用单因素和二元Logistic回归分析筛选影响ARC发生的危险因素,采用受试者工作特征曲线(ROC)分析危险因素对ARC的预测价值。结果:研究共纳入102例危重症患者,36例(35%)出现ARC,较之非ARC患者,ARC患者更年轻,使用正性肌力药、发生脑外伤和SIRS的频率更高,SOFA评分和万古霉素稳态谷浓度更低。Logistic回归显示,年龄(OR=0.955,95%CI:0.925~0.987)、脑外伤(OR=2.89,95%CI:1.003~8.327,)和SOFA评分(OR=0.687,95%CI:0.526~0.897)是ARC发生的的独立危险因素。年龄51岁为ROC曲线切割点,曲线下面积(AUC)为0.714,敏感度61.1%,特异度74.2%;SOFA评分7分为ROC曲线切割点分,AUC为0.739,敏感度45.5%,特异度94.4%。结论:年龄≤51岁、SOFA评分≤7分和颅脑外伤的危重症患者发生ARC的风险较高,易引起万古霉素治疗浓度不足,需引起临床医生的高度重视,早筛查、早识别、早干预是关键。

OBJECTIVE To explore the risk factors of augmented renal clearance(ARC) in critically ill patients treated with vancomycin.METHODS A retrospective study was conducted in patients receiving vacomycin 1 g q12 h admitted to department of intensive medical care from January 2016 to February 2019.Patients were grouped according to the presence of ARC which was defined by an estimated creatinine clearance(CrCl) ≥130 mL·(min·1.73 m2)-1,univariate and binary Logistic regression were used to analyze the risk factors of ARC in patients,and receiver operating characteristic curve(ROC) was drawn to evaluate its predictive value.RESULTS A total of 102 critically ill patients were included in the study,36(35%) had ARC.Compared with non-ARC patients,ARC patients were younger,used inotropes more often,had more frequent traumatic brain injury and SIRS,and had lower SOFA scores and steady-state trough concentrations of vancomycin.Logistic regression showed that age(OR=0.955,95% CI:0.925-0.987),traumatic brain injury(OR=2.89,95% CI:1.003-8.327,) and SOFA score(OR=0.687,95% CI:0.526-0.897) were independent risk factors for the development of ARC.Age 51 years was the ROC curve cut point,with an area under the curve(AUC) of 0.714,sensitivity 61.1%,and specificity 74.2%;SOFA score 7 was divided into ROC curve cut point points,with an AUC of 0.739,sensitivity 45.5%,and specificity 94.4%.CONCLUSION Critically ill patients aged≤51 years,SOFA score≤7 and traumatic brain injury have a higher risk of ARC,which is easy to cause insufficient therapeutic concentration of vancomycin and needs to be highly valued by clinicians.Early screening,early identification and early intervention are the key points.