血小板减少程度对老年脓毒症相关急性肾损伤患者短期预后的价值

The value of thrombocytopenia in the short-term prognosis of elderly patients with sepsis-related acute kidney injury

目的探讨老年脓毒症相关急性肾损伤(SA-AKI)患者血小板减少危险因素,进一步评估血小板减少程度是否与患者第28天死亡风险增加有关。方法选择2017年6月至2020年6月在我院ICU收治的老年SA-AKI患者。根据血小板计数分为血小板正常组(56例)和血小板减少组(72例),按照血小板减少程度进一步分为三组:PLT<20×10^(9)/L(A组,22例)、20×10^(9)/L≤PLT<50×10^(9)/L(B组,27例)、50×10^(9)/L≤PLT<100×10^(9)/L(C组,23例)。比较各组一般资料、临床基线指标、预后指标,评估血小板减少的危险因素,根据患者ICU住院时间、总住院时间以及患者是否死亡评估血小板计数对老年SA-AKI患者预后的影响,分析血小板减少程度与生存期的相关性。结果共纳入128例老年SA-AKI患者,其中男性73例,女性55例,59.4%患者在内科住院治疗,急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ)评分(15.5±3.3)分,有创机械通气占78.9%,正性肌力治疗占12.8%,56例患者血小板计数正常,72例患者发生了血小板减少,其中22例患者PLT<20×10^(9)/L,27例患者血小板计数在20~50×10^(9)/L,23例患者血小板计数在50~100×10^(9)/L。四组患者血流感染、革兰氏阴性菌、APACHEⅡ评分、降钙素原(PCT)差异有统计学意义(P<0.05)。进一步多因素Logistic回归显示,PCT是老年SA-AKI患者血小板减少的独立危险因素(OR=1.05,95%CI:1.00~1.10,P=0.042)。与血小板正常组相比,血小板减少组的28 d病死率明显高于血小板正常组,ICU住院时间、总住院时间延长(P<0.05)。Kaplan-Meier生存曲线提示,血小板减少组28 d累积生存率低于血小板正常组,且随血小板减少程度死亡风险增加(χ^(2)=31.479,P<0.001)。单因素Cox回归分析显示,血小板减少、血流感染、APACHEⅡ评分、PCT是老年SA-AKI患者28 d死亡的危险因素。多因素Cox分析显示,血流感染、APACHEⅡ评分是患者28 d死亡的独立危险因素,调整这些混杂因素后,血小板减少是患者死亡的独立危险因素,且血小板减少程度与死亡风险增加有关。结论老年SA-AKI患者普遍存在血小板减少,PCT升高增加血小板减少风险,血小板减少程度是此类患者28d病死率的独立危险因素。

Objective To investigate the risk factors of thrombocytopenia in elderly patients with sepsis-associated acute kidney injury(SA-AKI),and to further evaluate whether the degree of thrombocytopenia is related to the increased risk of death on day 28.Methods Elderly patients with SA-AKI admitted to ICU of our hospital from June 2017 to June 2020 were selected.The patients were divided into normal platelet group(56 cases)and thrombocytopenia group(72 cases)according to the platelet(PLT)count,and according to the degree of thrombocytopenia,they were further divided into three groups:PLT<20×10^(9)/L(group A,22 cases),20×109/L≤PLT<50×10^(9)/L(group B,27 cases),50×10^(9)/L≤PLT<100×10^(9)/L(group C,23 cases).The general data,clinical baseline indicators and prognostic indicators of each group were compared to evaluate the risk factors of thrombocytopenia.At the same time,the impact of platelet count on the prognosis of elderly patients with SA-AKI was evaluated according to the length of stay in ICU,total length of stay and whether the patient died,and the correlation between the degree of thrombocytopenia and survival was analyzed.Results A total of 128 elderly patients with SA-AKI were enrolled,including 73 males and 55 females.59.4%of the patients were hospitalized in the department of internal medicine.The APACHEⅡscore was(15.5±3.3)points,invasive mechanical ventilation accounted for 78.9%,positive inotropic therapy accounted for 12.8%,and 56 patients had normal platelet count.Thrombocytopenia occurred in 72 patients,including 22 patients with PLT<20×10^(9)/L,27 patients with platelet count in 20-50×10^(9)/L,and 23 patients with platelet count in 50-100×10^(9)/L.There were significant differences in bloodstream infection,Gram-negative bacteria,APACHEⅡscore and procalcitonin(PCT)among the four groups(P<0.05).Further multivariate logistic regression showed that PCT was an independent risk factor for thrombocytopenia in elderly patients with SA-AKI(OR=1.05,95%CI:1.00-1.10,P=0.042).Compared with the normal platelet group,the 28-day mortality rate of the thrombocytopenia group was significantly higher than that of the normal platelet group,while the length of stay in ICU and the total length of stay were prolonged(P<0.05).Kaplan-Meier survival curve showed that the 28-day cumulative survival rate of thrombocytopenia group was lower than that of normal platelet group,and the risk of death increased with the degree of thrombocytopenia(χ^(2)=31.479,P<0.001).Univariate Cox regression analysis showed that thrombocytopenia,bloodstream infection,APACHEⅡscore and PCT were risk factors for 28-day death in elderly patients with SA-AKI.Multivariate Cox analysis showed that bloodstream infection and APACHEⅡscore were independent risk factors for 28-day death.After adjusting these confounding factors,thrombocytopenia was an independent risk factor for death,and the degree of thrombocytopenia was related to the increased risk of death.Conclusions Thrombocytopenia is common in elderly patients with SA-AKI,and elevated PCT levels increase the risk of thrombocytopenia.The degree of thrombocytopenia is an independent risk factor for 28-day mortality in such patients.