创伤后急性肾损伤患者连续性肾脏替代治疗的疗效分析

Prognostic analysis of patients with post-traumatic acute kidney injury treated with continuous renal replacement therapy

目的:回顾性分析连续性肾脏替代治疗(CRRT)的创伤后急性肾损伤(AKI)患者的近期与远期预后及影响因素。方法:纳入2014年1月至2019年12月严重创伤后AKI并接受CRRT治疗的患者77例。随访截止2020年12月,分析患者28 d和90 d死亡率、肾功能恢复情况及其影响因素。结果:患者急性生理学与慢性健康状况评分系统Ⅱ(APACHEⅡ)评分为17.9±6.2分,创伤严重程度评分(ISS)为25(18,36)分,68例(88.3%)接受机械通气,62例(80.5%)应用血管活性药物,44例(57.1%)合并脓毒症。57例(74%)患者为AKI 3期,AKI 2期11例(14.3%)和AKI 1期9例(11.7%)。AKI发生至开始CRRT中位间隔时间为6(1.5,12.5)d,累计CRRT时间126(65.5,311.8)h。患者28d死亡率为24.7%(19例),开始CRRT时血磷水平是患者28d死亡的独立危险因素(HR=0.137,95%CI 0.038~0.491,P=0.002)。血磷预测患者28d死亡的cut-off值为1.0 mmol/L。血磷>1.0 mmol/L和≤1.0 mmol/L的生存率分别为87.2%和55.6%(P=0.01)。患者90 d死亡率54.5%(42例),总胆红素是患者90 d死亡的独立危险因素(HR=1.007,95%CI 1.002~1.011,P=0.003)。总胆红素预测患者90 d死亡的cut-off值为141.6μmol/L。总胆红素>141.6μmol/L者无一例生存。35例存活患者中,28例肾功能恢复正常,5例进展为慢性肾功能不全,1例需要维持性血液透析,1例失访。结论:需要CRRT的创伤后AKI患者病情危重,死亡率高。开始CRRT时血磷和总胆红素水平分别是预测患者28 d和90 d死亡的独立风险因素,部分存活患者进展至慢性肾脏病。

Objective:To retrospectively observe short and long-term prognosis and risk factors of severe post-traumatic acute kidney injury(AKI)patients receiving continuous renal replacement therapy(CRRT).Methodology:A retrospective analysis of 77 adult patients with severe post-traumatic AKI receiving CRRT from January 2014 to December 2019 was conducted.The deadline for follow-up is December 2020.28-day and 90-day mortality of patients and their risk factors were analyzed,as well as recovery of renal function.Results:Of the 77 patients enrolled,all patients had severe trauma,with acute physiology and chronic health evaluationⅡ(APACHEⅡ)score of 17.9±6.2,injury severity score(ISS)of 25(18,36).66(88.3%)of them requiring mechanical ventilation,62(80.5%)requiring vasoactive drugs,and 44(57.1%)suffered sepsis.Renal injury was mainly in the AKI stage 3(57 cases,74%),the remaining 11 cases(14.3%)in the AKI stage 2 and 9 cases(11.7%)in the AKI stage 1.The median interval between occurrence of AKI and start of CRRT was 6(1.5,12.5)days.The dose of CRRT was 3.64±0.78 L/h,and the cumulative treatment time of CRRT was 126(65.5,311.8)h.The 28-day hospitalized mortality rate was 24.7%(19 cases).Blood phosphorus level at the beginning of CRRT is an independent risk factor for 28-day death(HR=0.137,95%CI 0.038-0.491,P=0.002).The cut-off value of blood phosphorus predicting patient’s 28-day death was 1.0 mmol/L.The survival rates of serum phosphorus>1.0 and≤1.0 mmol/L were 87.2%and 55.6%respectively(P=0.01).The 90-day hospitalized mortality rate was 54.5%(42 cases),total bilirubin was an independent risk factor for 90-day death(HR=1.007,95%CI 1.002~1.011,P=0.003).The cut-off value of total bilirubin predicting patient’s 90-day death is 141.6μmol/L.None of the patients with total bilirubin>141.6μmol/L survived.Among the 35 surviving patients,renal function recovered in 28 patients,5 cases progressed to chronic renal insufficiency,1 case required maintenance hemodialysis.Conclusion:Post-traumatic AKI patients receiving CRRT are in critical condition and have a high mortality rate.Serum phosphate levels and total bilirubin levels at initiation of CRRT are independent risk factors for 28-day and 90-day death,some patients will progress to chronic kidney disease.