重症创伤患者急性肾损伤的临床特征及危险因素分析

Clinical features and risk factor analysis of severe trauma patients with acute kidney injury

目的探讨重症创伤患者急性肾损伤(Acute kidney injury,AKI)的临床特征,分析其危险因素及临床预后。方法回顾分析2018年7月至2020年12月期间南方医科大学附属小榄医院ICU收治的重症创伤患者临床资料,收集人口学资料、基础疾病、危重症评分、血肌酐、血红蛋白、治疗方案、输血量及临床结局等,建立临床数据库。根据改善全球肾脏病预后组织(KDIG0)标准进行AKI诊断及分级,根据创伤主要部位进行分型,比较不同组间临床资料及检验结果,分析重症创伤患者发生AKI的临床特点及预后情况,并采用Logistic回归分析重症创伤患者发生AKI的危险因素。结果(1)共有175例重症创伤患者符合标准纳入研究,AKI发生率为30.9%(54/175),其中AKI 1期29例(16.6%),AKI 2期15例(8.6%),AKI 3期10例(5.7%)。整个研究人群住院期间肾脏替代治疗率为4%,住院病死率为5.7%,28 d病死率16.6%。(2)AKI组的年龄、休克人数占比、入ICU血肌酐、APACHEⅡ评分及ISS评分均明显高于非AKI组,差异有统计学意义(P<0.05);两组间的性别、基础疾病(高血压病及糖尿病)、入ICU血红蛋白水平及造影剂使用率等方面,差异无统计学意义(P>0.05)。与非AKI组比较,AKI组手术治疗率更高(63%vs.44.6%)、输血量更多[875(720,1110)mL&670(610,750)mL]、住ICU时间更长[6(4,11)d&4(2.5,7.5)d]、机械通气比例更高(96.3 vs.81%)、肾脏替代治疗需求率更高(13%vs.0),住院病死率(13%vs.2.5%)及28 d病死率(25.9%vs.12.4%)更高,差异有统计学意义(P<0.05)。(3)不同类型重症创伤患者的AKI发生率不同,以腹部创伤组AKI发生率最高(50%),其入ICU时血肌酐及住院期间血肌酐峰值,明显高于其他类型重症创伤患者,差异有统计学意义(P<0.05)。(4)Logistic回归分析显示:年龄[OR=1.020,95%CI(1.003,1.038),P=0.024]、APACHEⅡ评分[OR=1.137,95%CI(1.053,1.228),P=0.001]、休克[OR=1.102,95%CI(0.906,1.208),P=0.034]、入ICU血肌酐[OR=1.068,95%CI(1.036,1.102),P=0.000]、手术治疗[OR=4.205,95%CI(1.446,12.233),P=0.008]、输血量[OR=1.006,95%CI(1.002,1.009),P=0.001]是重症创伤患者发生AKI的独立危险因素。结论重症创伤患者AKI发病率较高并影响临床预后,不同类型重症创伤AKI发病率不同。年龄、APACHEⅡ评分、休克、入ICU血肌酐、手术治疗、输血量是重症创伤患者发生AKI的独立危险因素。

Objective To investigate the clinical characteristics of the severe trauma patients with Acute kidney injury(AKI),and analyze the risk factors and clinical prognosis.Methods Clinical data of severe trauma patients admitted to ICU of Xiaolan Hospital of Southern Medical University,from July 2018 to December 2020 were retrospectively analyzed.Demographic data,basic diseases,critical disease score,serum creatinine,hemoglobin,treatment options,blood transfusion volume,and clinical outcomes were collected to establish a clinical database.AKI was diagnosed and graded according to the Kidney Disease Improving Global Outcomes(KDIGO)criterion,and trauma type was classified according to the main injury part.The clinical data and laboratory examination of different groups were compared to analyze the clinical characteristics and prognosis in severe trauma patients.The risk factors of AKI in severe trauma patients were analyzed by Logistic regression.Results(1)A total of 175 patients with severe trauma were eligible for inclusion,and the incidence of AKI was 30.9%(54/175),including 29 patients with AKI stage 1(16.6%),15 patients with AKI stage 2(8.6%),and 10 patients with AKI stage 3(5.7%).In the cohort,the rate of in-hospital renal replacement therapy was 4%,in-hospital mortality was 5.7%,and 28-day mortality was 16.6%.(2)The age,shock patients,ICU admission serum creatinine,APACHEⅡscore and ISS score of AKI group were signifi cantly higher than those of non-AKI group(P<0.05).There were no signifi cant differences between the two groups in gender,underlying diseases(hypertension and diabetes),ICU admission hemoglobin level and contrast agent utilization rate(P>0.05).Compared with the non-AKI group,AKI group had higher rates of surgical treatment(63%vs.44.6%),more blood transfusion[875(720,1110)mL&670(610,750)mL],longer ICU stay[6(4,11)d&4(2.5,7.5)d],and higher rates of mechanical ventilation(96.3%vs.81%),renal replacement therapy rate(13%vs.0),in-hospital mortality(13%vs.2.5%)and 28-day mortality(25.9%vs.12.4%),the differences were statistically signifi cant(P<0.05).(3)The incidence of AKI was different in patients with different types of severe trauma,and the abdominal trauma group with a highest rate(50%).The serum creatinine at ICU admission and the peak value during hospitalization in abdominal trauma group were significantly higher than those in other injury types(P<0.05).(4)Logistic regression analysis showed Age[OR=1.020,95%CI(1.003,1.038),P=0.024],APACHEⅡscore[OR=1.137,95%CI(1.053,1.228),P=0.001],shock[OR=1.102,95%CI(0.906,1.208),P=0.034],ICU admission serum creatinine[OR=1.068,95%CI(1.036,1.102),P=0.000],surgical treatment[OR=4.205,95%CI(1.446,12.233),P=0.008],blood transfusion volume[OR=1.006,95%CI(1.002,1.009),P=0.001]were independent risk factors for AKI in severe trauma patients.Conclusions Severe trauma patients yield a high incidence of AKI infl uencing clinical prognosis.The incidence of AKI varies with different types of severe trauma.Age,APACHEⅡscore,shock,ICU admission serum creatinine,surgical treatment,and blood transfusion volume are independent risk factors for AKI in severe trauma patients.