血磷对接受连续肾脏替代治疗的脓毒症合并急性肾损伤患者90天死亡的预测价值

Predictive value of serum phosphorus in 90-day mortality of sepsis patients with acute kidney injury undergoing continuous renal replacement therapy

目的探讨血磷对接受连续肾脏替代治(CRRT)的脓毒症合并急性肾损伤(SI-AKI)患者90天死亡的预测价值。方法回顾性连续收集2009年1月至2016年9月韩国Health System Severance医院和Ilsan医院ICU中接受CRRT的SI-AKI患者。原始研究收集了CRRT启动时患者的人口学资料、临床信息、生化指标、CRRT相关信息、CRRT启动时血磷(P^(3-))、CRRT启动后24 h血磷(24 h P^(3-))和两者差值(ΔP^(3-))。本研究采用Kaplan-Meier生存曲线、log-rank检验、比例风险回归模型(Cox)和趋势性检验探究P^(3-)、24 h P^(3-)和ΔP^(3-)对90天死亡的独立作用,同时对P^(3-)、24 h P^(3-)和ΔP^(3-)和90天死亡进行饱和阈值效应分析。分别构建P^(3-)、24 h P^(3-)和ΔP^(3-)预测90天死亡的预测模型,计算受试者工作特征曲线下面积(AUC)和一致性指数(Harrell′s C-index)。结果K-M曲线和log-rank检验、Cox回归和趋势性检验显示,三种血磷水平均和90天死亡独立正相关(HR=1.10,95%CI 1.05~1.14,P<0.001;HR=1.17,95%CI 1.13~1.21,P<0.001;HR=1.07,95%CI 1.02~1.11,P=0.002)。随着三种血磷三分组等级增加,患者90天死亡风险逐渐增加且增加趋势是显著的(趋势性检验P<0.05)。饱和阈值效应分析提示,24 h P^(3-)与90天死亡间存在饱和阈值效应,饱和折点为7.5 mg/dL。P^(3-)、24 h P^(3-)和ΔP^(3-)单独预测该类患者的90天死亡准确度较差。结论在韩国人群中血磷与接受CRRT的SI-AKI患者90天死亡独立正相关,但预测死亡的准确度较差。

Objective To explore the value of serum phosphorus in 90-day mortality of sepsis patients with acute kidney injury(SI-AKI)undergoing continuous renal replacement therapy(CRRT).Methods To retrospectively collect SI-AKI patients undergoing CRRT in the ICUs of Health System Severance Hospital and Ilsan Hospital in South Korea from January 2009 to September 2016.The demographic data,clinical characteristics,biochemical indicators,CRRT-related information,serum phosphorus at CRRT initiation(P^(3-)),serum phosphorus after 24 hours of CRRT initiation(24 h P^(3-))and the difference between them(ΔP^(3-)).Kaplan-Meier curve,log-rank test,proportional hazard regression model(Cox)and trend test were conducted to analyze the independent effect of P^(3-),24 h P^(3-)andΔP^(3-)on 90-day mortality,respectively.At the same time,we used piecewise linear model and recursive method to analyze the threshold and saturation effects of P^(3-),24 h P^(3-)andΔP^(3-)and 90-day mortality.The prediction models for 90-day mortality were individually constructed with P^(3-),24 h P^(3-)andΔP^(3-).AUC and Harrell′s C-index were calculated to evaluate model performance.Results Kaplan-Meier curve and log-rank test,Cox regression and trend test revealed P^(3-),24 h P^(3-)andΔP^(3-)were independently positively associated with 90-day mortality(HR=1.10,95%CI 1.05-1.14,P<0.001;HR=1.17,95%CI 1.13-1.21,P<0.001;HR=1.07,95%CI 1.02-1.11,P=0.002).In addition,as tertile groups of P^(3-),24 h P^(3-)andΔP^(3-)increased,the mortality risk of 90-day increased gradually and the increasing trend was significant(P for trend<0.05).The threshold and saturation effect analysis indicated the presence of a saturation effect between 24 h P^(3-)and 90-day mortality with a saturation inflection of 7.5 mg/dL.P^(3-),24 h P^(3-)andΔP^(3-)alone has poor accuracy in predicting 90-day mortality in SI-AKI patients.Conclusions Serum phosphorus was independently positively correlated with 90-day mortality in SI-AKI patients undergoing CRRT in South Korean.