急性呼吸窘迫综合征并发急性肾损伤患者预后不良的影响因素分析

Influencing factors of poor prognosis of patients with acute respiratory distress syndrome after acute kidney injury

目的观察急性呼吸窘迫综合征(ARDS)并发急性肾损伤(AKI)患者预后情况,探讨其预后不良的影响因素。方法2018年1月—2022年10月河南省人民医院诊治ARDS并发AKI患者265例,根据并发AKI后28 d内预后情况分为死亡组154例和生存组111例,比较2组合并症、ARDS病因、入ICU 24 h内急性生理学和慢性健康状况评估Ⅱ(APACHEⅡ)评分、肾功能、C反应蛋白、降钙素原、动脉血气、氧合指数,入ICU第1天体液平衡、入ICU第2天累积体液平衡、肾功能早期恢复情况、AKI分期等临床资料;采用多因素Cox回归分析ARDS并发AKI患者28 d内死亡的影响因素。结果死亡组年龄[69.50(59.75,77.00)岁]、APACHEⅡ评分[19.00(15.00,25.00)分]、血乳酸水平[2.14(1.52,3.14)mmol/L]及合并恶性肿瘤(19.5%)、合并冠心病(27.9%)、肺源性ARDS(79.2%)、入ICU第2天累积体液正平衡(63.0%)、AKI 2~3期(72.1%)、肾功能早期未恢复(75.3%)比率均高于生存组[63.00(49.00,73.00)岁、16.00(12.00,21.00)分、1.74(1.34,2.70)mmol/L、8.1%、17.1%、66.7%、48.6%、50.5%、38.7%](P<0.05),pa(O_(2))[66.15(57.83,81.30)mmHg]、动脉血氧饱和度[92.15(88.38,95.23)%]、氧合指数[109(74,156)mmHg]均低于生存组[74.70(65.50,87.90)mmHg、94.30(91.80,96.40)%、157(99,220)mmHg](P<0.05),合并高血压、糖尿病、脑血管病比率,入ICU 24 h内发生意识障碍、使用升压药物、行有创机械通气、入ICU第1天体液正平衡比率及序贯器官衰竭评估评分、白细胞计数、血小板计数、红细胞计数、血红蛋白、白蛋白、谷丙转氨酶、谷草转氨酶、血肌酐、血尿酸、估算肾小球滤过率、C反应蛋白、降钙素原、pH值、碳酸氢根、pa(CO_(2))与生存组比较差异均无统计学意义(P>0.05)。合并恶性肿瘤(HR=1.983,95%CI:1.301~3.023,P=0.001)、入ICU第2天累积体液正平衡(HR=1.428,95%CI:1.013~2.015,P=0.042)、肾功能早期未恢复(HR=1.936,95%CI:1.238~3.027,P=0.004)、氧合指数(HR=0.647,95%CI:0.447~0.937,P=0.021)是ARDS并发AKI患者28 d内死亡的影响因素。结论合并恶性肿瘤、入ICU第2天累积体液正平衡、肾功能早期未恢复、氧合指数降低与ARDS并发AKI患者预后不良相关。

Objective To observe the prognosis of acute respiratory distress syndrome(ARDS)patients after acute kidney injury(AKI),and to investigate the influencing factors of poor prognosis.Methods Totally 265 patients with ARDS complicated with AKI were diagnosed and treated in Henan Provincial People's Hospital from January 2018 to October 2022,and were divided into death group(n=154)and survival group(n=111)according to the prognosis within28 d after AKI.The complications,causes of ARDS,acute physiology and chronic health evaluationⅡ(APACHEⅡ)score within 24 h after admission to ICU,renal function,C-reactive protein,procalcitonin,arterial blood gas,oxygenation index,fluid balance by day 1 after admission to ICU,accumulated fluid balance by day 2 after admission to ICU,early recovery status of renal function,and AKI stage were compared between two groups.Multivariate Cox regression was used to analyze the influencing factors of death within 28 d after AKI in patients with ARDS.Results The patients were older in death group[69.50(59.75,77.00)years]than in survival group[63.00(49.00,73.00)years](p<0.05).The APACHEⅡscore,blood lactic acid level,and percentages of patients with malignant tumors,coronary heart disease,pulmonary ARDS,positive accumulated fluid balance by day 2 after admission to ICU,AKI stage 2 to 3 and early recovery failure of renal function were higher in death group[19.00(15.00,25.00),2.14(1.52,3.14)mmol/L,19.5%,27.9%,79.2%.63.0%,72.1%,75.3%]than those in survival group[16.00(12.00,21.00),1.74(1.34,2.70)mmol/L,8.1%,17.1%,66.7%,48.6%,50.5%,38.7%](P<0.05),and the pa(O_(2)),arterial oxygen saturation and oxygenation index were lower in death group[66.15(57.83,81.30)mmHg,92.15(88.38,95.23)%,109(74,156)mmHg]than those in survival group[74.70(65.50,87.90)mmHg,94.30(91.80,96.40)%,157(99,220)mmHg](P<0.05).There were no significant differences in the percentages of patients with hypertension,diabetes,cerebrovascular diseases,disturbance of consciousness within 24 h after admission to ICU,use of vasopressor drugs,invasive mechanical ventilation,and some data by day 1 after admission to ICU such as positive accumulated fluid balance,sequential organ failure assessment score,white blood cell count,platelet count,red blood cell count,hemoglobin,albumin,glutamic-pyruvic transaminase,glutamic-oxaloacetic transaminase,serum creatinine,blood uric acid,estimated glomerular filtration rate,C-reactive protein,proealcitonin,pH value,bicarbonate radical and pa(CO_(2))between two groups(P>0.05).Malignant tumors(HR=1.983,95%CI:1.301-3.023,P=0.001),positive accumulated fluid balance by day 2 after admission to ICU(HR=1.428,95%CI:1.013-2.015,P=0.042),early recovery failure of renal function(HR=1.936,95%CI:1.238-3.027,P=0.004),and oxygenation index(HR=0.647,95%CI:0.447-0.937,P=0.021)were the influencing factors of death within 28 d after AKI in patients with ARDS.Conclusion The complication of malignant tumors,positive accumulated fluid balance by day 2 after admission to ICU,early recovery failure of renal function,and decreased oxygenation index are involved in poor prognosis of patients with ARDS after AKI.