急诊高钾血症治疗现状及预后影响因素研究

Treatment and factors associated with prognosis of hyperkalemia in the emergency department

目的:调查急诊高钾血症患者的治疗现状和预后,分析急诊高钾血症患者院内全因死亡的影响因素。方法:利用电子信息系统,提取2019年6月1日至2020年5月31日北京协和医院急诊高钾血症患者〔年龄≥18岁,血清电解质检查钾离子(K +)浓度≥5.5 mmol/L〕的人口统计学特征、基础疾病、实验室检查结果、降钾治疗措施及预后,根据预后将患者分为死亡组及存活组,采用单因素分析及Cox回归分析急诊高钾血症患者院内全因死亡的影响因素。 结果:共纳入高钾血症患者579例,其中男性310例(53.5%),女性269例(46.5%);中位年龄64(22)岁;轻度、中度、重度高钾血症患者分别有317例(54.7%)、143例(24.7%)、119例(20.6%)。499例(86.2%)患者接受了降钾治疗,共有44种降钾治疗方案,其中糖+胰岛素(I+G,61.3%)、排钾利尿剂(Diu,57.2%)、碳酸氢钠(SB,41.9%)、钙剂(CA,44.4%)在急诊科较常用,糖+胰岛素+钙剂+排钾利尿剂+碳酸氢钠(I+G+CA+Diu+SB)四联降钾治疗方案是急诊科最常用的降钾方案。高钾血症患者血清K +水平越高,联合降钾治疗比例越高,血液净化(HD)比例越高(轻度、中度、重度患者联合降钾比例分别为58.4%、82.5%、94.8%,HD比例分别为9.7%、13.3%、16.0%)。随着降钾治疗种类增多,血钾降至正常的比例增高,6种降钾方式联合治疗患者血钾降至正常的比例达100%。不同降钾治疗方式中,HD治疗者血钾降至正常的比例最高,达93.8%。579例患者中院内死亡111例(19.2%)。Cox回归分析显示,合并心功能不全的患者死亡风险高〔风险比( HR)=1.757,95%可信区间(95% CI)为1.155~2.672, P=0.009〕;血钾降至正常( HR=0.248,95% CI为0.155~0.398, P=0.000)及使用Diu( HR=0.335,95% CI为0.211~0.531, P=0.000)的患者死亡风险低。 结论:急诊降钾治疗方案异质性较大,合并心功能不全的高钾血症患者病死率高,血钾降至正常的患者病死率低。

Objective To survey treatment and prognosis of hyperkalemia patients in the emergency department and to analyze factors associated with all-cause in-hospital mortality.Methods We implemented electronic hospital information system,extracted demographic characteristics,underlying diseases,laboratory findings,potassium lowering therapy and prognosis of hyperkalemia patients[age≥18 years,serum potassium(K+)concentration≥5.5 mmol/L]in the emergency department of Peking Union hospital in Beijing between June 1st 2019 to May 31st 2020.The enrolled subjects were divided into the non-survival group and the survival group according to their prognosis.Univariate analysis and Cox regression model were adopted to analyze factors affecting all-cause in-hospital mortality of hyperkalemia patients.Results A total of 579 patients[median age 64(22)years;310 men(53.5%)and 269 women(46.5%)]with hyperkalemia were enrolled,among which,317(54.7%),143(24.7%)and 119(20.6%)were mild,moderate,and severe hyperkalemia,respectively.499(86.20%)patients received potassium-lowering therapy,forty-four treatment regimens were administered.Insulin and glucose(I+G,61.3%),diuretics(Diu,57.2%),sodium bicarbonate(SB,41.9%)and calcium gluconate/chloride(CA,44.4%)were commonly used for the treatment of hyperkalemiain the emergency department.The combination of insulin and glucose,calcium gluconate/chloride,diuretics and sodium bicarbonate(I+G+CA+Diu+SB)was the most favored combined treatment regimen of hyperkalemia in the emergency department.The higher serum potassium concentration,the higher proportion of administrating combined treatment regimen and/or hemodialysis(HD)(the proportion of administrating combined treatment regimen in mild,moderate,and severe hyperkalemia patients were 58.4%,82.5%and 94.8%;the proportion of administrating HD in mild,moderate,and severe hyperkalemia patients were 9.7%,13.3%and 16.0%,respectively).The proportion of achievement of normokalaemia elevated as the kinds of potassium lowering treatment included in the combined treatment regimen increased.The proportion of achievement of normokalaemia was 100%in the combined treatment regimen including 6 kinds of potassium lowering therapy.Among various potassium lowering treatments,HD contributed to the highest rate of achievement of normokalaemia(93.8%).111 of 579(19.20%)hyperkalemia patients died in hospital.Cox regression model revealed that complicated with cardiac dysfunction predicted higher mortality[hazard ratio(HR)=1.757,95%confidence interval(95%CI)was 1.155-2.672,P=0.009].Achievement of normokalaemia and administration of diuretics attributed to lower mortality(HR=0.248,95%CI was 0.155-0.398,P=0.000;HR=0.335,95%CI was 0.211-0.531,P=0.000,respectively).Conclusions Treatment of hyperkalemia in the emergency department were various.Complicated with cardiac dysfunction were associated with higher mortality.Achieving normokalaemia was associated with decreased mortality.