急性胰腺炎患者30 d内主要肾脏不良事件的危险因素分析

Analysis of risk factors of major adverse kidney events within 30 days in patients with acute pancreatitis

目的分析急性胰腺炎(AP)患者发生30 d内主要肾脏不良事件(MAKE30)的危险因素。方法采用回顾性队列研究方法, 选择2019年6月至2021年6月苏州大学附属第一医院收治的首次诊断为AP且发病时间<72 h的162例患者。根据患者入院治疗后MAKE30发生与否分为MAKE30组和非MAKE30组, MAKE30定义为任何原因引起的死亡、新的肾脏替代治疗(RRT)和持续性肾功能不全(PRD)。比较两组患者入院时的临床资料;采用多因素Logistic回归法分析MAKE30的独立危险因素, 并建立回归方程作为MAKE30定量预测模型;绘制受试者工作特征曲线(ROC曲线), 分析定量预测模型的预测价值。结果 162例患者均纳入最终分析, 其中MAKE30组32例, 非MAKE30组130例。单因素分析显示, 与非MAKE30组比较, MAKE30组患者体质量指数(BMI)、重度AP比例及入院时急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)、序贯器官衰竭评分(SOFA)、血尿素氮(BUN)、血肌酐(SCr)、C-反应蛋白(CRP)、HCO_(3)^(-)、Cl^(-)水平和高氯血症比例均显著升高。多因素Logistic回归分析显示, 入院时APACHEⅡ评分〔优势比(OR)=1.659, 95%可信区间(95%CI)为1.426~1.956, P=0.009〕、SOFA评分(OR=1.501, 95%CI为1.236~1.840, P=0.014)和高氯血症(OR=1.858, 95%CI为1.564~2.231, P=0.004)是AP患者发生MAKE30的独立危险因素。通过上述危险因素建立MAKE30回归方程〔Logit(P)=0.063+0.525×APACHEⅡ评分+0.328×SOFA评分+0.895×高氯血症〕, 作为MAKE30定量预测模型。ROC曲线分析显示, 模型预测MAKE30的ROC曲线下面积(AUC)为0.846(95%CI为0.774~0.923, P=0.001)。根据入院时血Cl-水平将患者分为高氯血症(Cl-≥110 mmol/L, n=19)和非高氯血症(Cl-<110 mmol/L, n=143)两个亚组, 结果显示, 与非高氯血症组比较, 高氯血症组MAKE30和急性肾损伤(AKI)的发生率显著增加(MAKE30:68.4%比13.3%, AKI:89.5%比43.4%), 入院时BUN、SCr水平显著升高〔BUN(mmol/L):9.3±2.5比5.9±1.1, SCr(μmol/L):162.3±26.4比78.6±9.2〕, 总住院时间和重症监护病房(ICU)住院时间显著延长〔总住院时间(d):10.2±1.6比5.6±1.2, ICU住院时间(d):6.2±1.0比3.1±0.6〕, 48 h、72 h累积静脉输液量显著增加(mL:48 h为7 235.9±1 025.3比5 659.6±956.7, 72 h为11 052.6±1 659.8比7 156.9±1 052.4), 差异均有统计学意义(均P<0.01)。结论 MAKE30可作为评估AP患者短期临床预后的重要指标, 入院时APACHEⅡ评分、SOFA评分及高氯血症是其主要危险因素;根据3个指标构建的MAKE30风险模型有较好的预测效能;AP伴高氯血症患者是发生MAKE30的高危人群, 应引起临床的高度重视。

Objective To analyze the risk factors of major adverse kidney events within 30 days(MAKE30)in patients with acute pancreatitis(AP).Methods A retrospective cohort study was conducted.A total of 162 patients who were first diagnosed with AP in the First Affiliated Hospital of Soochow University from June 2019 to June 2021 and the onset time was less than 72 hours were enrolled.Patients were divided into MAKE30 group and non-MAKE30 group according to the occurrence of MAKE30 after hospitalization.MAKE30 was defined as death from any cause,new renal replacement therapy(RRT),and persistent renal insufficiency(PRD).The clinical data of the two groups at admission were compared.The independent risk factors of MAKE30 were analyzed by multivariate Logistic regression method,and a regression equation was established as a quantitative prediction model of MAKE30.Receiver operator characteristic curve(ROC curve)was drawn to analyze the prediction of the quantitative prediction model value.Results All 162 patients were included in the final analysis,including 32 in the MAKE30 group and 130 in the non-MAKE30 group.Univariate analysis showed that compared with the non-MAKE30 group,the body mass index(BMI),the proportion of severe AP,and the acute physiology and chronic health evaluationⅡ(APACHEⅡ)score,the sequential organ failure assessment(SOFA)score,blood urea nitrogen(BUN),serum creatinine(SCr),C-reactive protein(CRP),HCO_(3)^(-),Cl^(-) levels and the proportion of hyperchloremia at admission in the MAKE30 group were significantly increased.Multivariate Logistic regression analysis showed that APACHEⅡscore at admission[odds ratio(OR)=1.659,95%confidence interval(95%CI)was 1.426-1.956,P=0.009],SOFA score(OR=1.501,95%CI was 1.236-1.840,P=0.014)and hyperchloremia(OR=1.858,95%CI was 1.564-2.231,P=0.004)were independent risk factors for MAKE30 in AP patients.The MAKE30 regression equation was established by the above risk factors[Logit(P)=0.063+0.525×APACHEⅡscore+0.328×SOFA score+0.895×hyperchloremia],which was used as the MAKE30 quantitative prediction model.ROC curve analysis showed that the area under the ROC curve(AUC)of the model for predicting MAKE30 was 0.846(95%CI was 0.774-0.923,P=0.001).The patients were divided into two subgroups with hyperchloremia(Cl-≥110 mmol/L,n=19)and non-hyperchloremia(Cl-<110 mmol/L,n=143)according to the blood Cl-level at admission.The incidence of MAKE30 and acute kidney injury(AKI)in the hyperchloremia group was significantly increased(MAKE30:68.4%vs.13.3%,AKI:89.5%vs.43.4%),and the levels of BUN and SCr at admission were significantly increased[BUN(mmol/L):9.3±2.5 vs.5.9±1.1,SCr(μmol/L):162.3±26.4 vs.78.6±9.2],the total length of hospital stay and length of intensive care unit(ICU)stay were significantly longer[total length of hospital stay(days):10.2±1.6 vs.5.6±1.2,length of ICU stay(days):6.2±1.0 vs.3.1±0.6],the cumulative intravenous infusion volume increased significantly at 48 hours and 72 hours(mL:7235.9±1025.3 vs.5659.6±956.7 at 48 hours,11052.6±1659.8 vs.7156.9±1052.4 at 72 hours),differences were statistically significant(all P<0.01).Conclusions MAKE30 can be used as an important indicator to evaluate the short-term clinical prognosis of AP patients.APACHEⅡscore,SOFA score and hyperchloremia at admission are the main risk factors.The risk model of MAKE30 based on these three indicators has good predictive performance.AP patients with hyperchloremia are at high risk of developing MAKE30,which should be highly regarded in clinical practice.