营养风险评分对脓毒症相关性急性肾损伤患者预后的临床价值

Clinical value of nutritional risk scores in patients with sepsis associated acute renal injury

目的:探讨体质量指数(BMI)、白蛋白(ALB)、营养风险筛查2002(NRS 2002)和重症营养风险评分(NUTRIC)对脓毒症相关性急性肾损伤(AKI)患者28 d预后的临床价值。方法:本研究为前瞻性队列研究,以2018年12月1日至2020年12月1日中国康复研究中心急诊重症监护室(EICU)收治的脓毒症患者为研究对象,连续观察7 d,将发生脓毒症相关性AKI的患者纳入本研究。记录患者的性别、年龄、BMI、基础疾病、有无休克、受累器官数、住院时间、ALB、机械通气(MV)和血管活性药物使用情况以及序贯器官衰竭评分(SOFA)、快速序贯器官衰竭评分(qSOFA)及急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ),并计算NRS 2002评分和NUTRIC评分。采用Cox回归模型分析脓毒症相关性AKI患者28 d死亡的危险因素;绘制受试者工作特征曲线(ROC曲线)并计算ROC曲线下面积(AUC),分析BMI、ALB、NRS 2002评分以及NUTRIC评分预测脓毒症相关性AKI患者28 d死亡的价值;利用Kaplan-Meier生存曲线分析NRS 2002评分分层以及NUTRIC评分分层对脓毒症相关性AKI患者28 d预后的影响。结果:共纳入140例脓毒症相关性AKI患者,28 d内存活73例,死亡67例,28 d病死率为47.9%(67/140)。存活组患者的BMI明显高于死亡组〔kg/m 2:22.0(19.5,25.6)比20.7(17.3,23.9),P<0.05〕,NRS 2002评分和NUTRIC评分均明显低于死亡组〔NRS 2002评分(分):5(4,6)比7(6,7),NUTRIC评分(分):6(5,7)比7(6,9),均P<0.05〕;存活组ALB略高于死亡组,但差异无统计学意义。Cox回归分析显示,NRS 2002评分以及NUTRIC评分是脓毒症相关性AKI患者28 d死亡的独立危险因素。ROC曲线分析显示,NUTRIC评分对脓毒症相关性AKI患者28 d死亡的预测能力最强〔AUC为0.785,95%可信区间(95%CI)为0.708~0.850〕,其次为NRS 2002评分(AUC为0.728,95%CI为0.647~0.800),但两者之间比较差异无统计学意义;BMI和ALB的预测能力差。Kaplan-Meier生存曲线分析显示,NRS 2002评分≥5分患者的预后明显差于NRS 2002评分<5分患者(28 d累积生存率:42.1%比75.6%,Log-Rank检验:2=11.884,P=0.001),NUTRIC评分≥6分患者的预后明显差于NUTRIC评分<6分患者(28 d累积生存率:40.4%比86.1%,Log-Rank检验:2=19.026,P=0.000)。结论:脓毒症相关性AKI患者营养风险高,NRS 2002评分和NUTRIC评分均对脓毒症相关性AKI患者预后有较好的预测价值,BMI和ALB预测价值较低。因NUTRIC评分计算复杂,可能NRS 2002评分更适合急诊科。

Objective To investigate the clinical value of nutritional indexes including body mass index(BMI),albumin(ALB),nutrition risk screening 2002(NRS 2002)and the nutrition risk in critically ill score(NUTRIC)in 28-day prognosis of patients with sepsis related acute kidney injury(AKI).Methods A prospective cohort study was conducted.Patients with sepsis treated in the emergency intensive care unit(EICU)of China Rehabilitation Research Center from December 1,2018 to December 1,2020 were observed for 7 days.Patients with sepsis related AKI were enrolled in this study.The gender,age,BMI,basic diseases,shock,number of affected organs,length of hospital stay,ALB,mechanical ventilation(MV)and vasoactive drug use,sequential organ failure score(SOFA),rapid sequential organ failure score(qSOFA)and acute physiology and chronic health evaluationⅡ(APACHEⅡ)were recorded.The NRS 2002 score and NUTRIC score were calculated.Cox regression model was used to analyze the risk factors of 28-day mortality in patients with sepsis related AKI.The receiver operator characteristic curves(ROC curves)were drawn and the areas under the ROC curves(AUC)were calculated,and the value of BMI,ALB,NRS 2002 score and NUTRIC score was analyzed to predict 28-day mortality in patients with sepsis related AKI.Kaplan Meier survival curves were used to analyze the effects of NRS 2002 score and NUTRIC score stratification on the 28 day prognosis of patients with sepsis related AKI.Results A total of 140 patients with sepsis related AKI were enrolled,including 73 survival patients and 67 died patients within 28 days.The 28-day mortality was 47.9%(67/140).BMI in the survival group was significantly higher than that in the death group[kg/m2:22.0(19.5,25.6)vs.20.7(17.3,23.9),P<0.05],and NRS 2002 score and NUTRIC score were significantly lower than those in the death group[NRS 2002 score:5(4,6)vs.7(6,7),NUTRIC score:6(5,7)vs.7(6,9),both P<0.05].The ALB of the survival group was slightly higher than that of the death group,but the difference was not statistically significant.Cox regression analysis showed that NRS 2002 score and NUTRIC score were independent risk factors for 28-day death in patients with sepsis related AKI.ROC curve analysis showed that NUTRIC score had the strongest predictive ability for 28-day death[AUC=0.785,95%confidence interval(95%CI)was 0.708-0.850],followed by NRS 2002 score(AUC=0.728,95%CI was 0.647-0.800),but there was no significant difference between them.Compared with NRS 2002 score,the predictive ability of BMI and ALB was poor.Kaplan-Meier curve analysis showed that the prognosis of patients with NRS 2002 score≥5 was significantly worse than that of patients with NRS 2002 score<5(28-day cumulative survival rate:42.1%vs.75.6%,Log-Rank test:2=11.884,P=0.001),and the prognosis of patients with NUTRIC score≥6 was significantly worse than that of patients with NUTRIC score<6(28-day cumulative survival rate:40.4%vs.86.1%,Log-Rank test:2=19.026,P=0.000).Conclusions Patients with sepsis related AKI have high nutritional risk.Both NRS 2002 score and NUTRIC score have good predictive value for the prognosis of patients with sepsis related AKI,while BMI and ALB have low predictive value.Due to the complex calculation of NUTRIC score,NRS 2002 score may be more suitable for emergency department.