急性肾损伤与非外科术后心脏重症患者临床结局的相关性分析

Association between acute kidney injury and clinical outcomes in non-surgical patients receiving intensive cardiac care

目的探讨中国大型非外科心脏重症监护室(intensive cardiac care unit,ICCU)中急性肾损伤(acute kidney injury,AKI)患者临床特征、院内临床结局以及短期随访生存率。方法回顾性纳入2016年6月—2017年5月入住四川大学华西医院心脏内科ICCU的患者,AKI诊断与分期基于改善全球肾脏病预后组织标准,院内复合终点事件定义为全因死亡或极其危重状态下自动出院,对未发生院内复合终点事件的患者进行随访,确定研究期间是否发生全因死亡。分析AKI与院内复合终点事件以及无院内复合终点事件患者短期随访临床结局的相关性。正态分布计量资料采用均数±标准差表示,非正态分布计量资料采用中位数(下四分位数,上四分位数)表示。结果共纳入2083例患者,平均年龄(65.5±14.6)岁,其中女性681例(占32.7%)。AKI患病率为15.0%(312/2083),其中1、2、3期AKI分别为6.9%、4.9%、3.2%。相比于无AKI组,AKI组年龄更大[(68.9±14.3)vs.(64.9±14.6)岁,P<0.001],查尔斯合并症指数更高[4.0(3.0,6.0)vs.2.0(1.0,3.0),P<0.001],牛津急性疾病严重程度评分更高[32.0(24.0,41.2)vs.21.0(16.0,26.0)分,P<0.001]。174例(8.4%)患者发生院内复合终点事件,多因素logistic回归分析显示随着AKI分期级别的增加,院内复合终点事件的风险越高[AKI 1期vs.无AKI:比值比(odds ratio,OR)=1.13,95%置信区间(confidence interval,CI)(0.57,2.24);AKI 2期vs.无AKI:OR=2.21,95%CI(1.08,4.51);AKI 3期vs.无AKI:OR=10.88,95%CI(4.50,26.34);P趋势<0.001]。对未发生院内复合终点事件的患者进行的中位时间为13.5(10.7,16.6)个月的随访显示,全因死亡率为5.5%(105/1909),多因素Cox回归分析显示AKI与全因死亡独立相关[风险比=2.27,95%CI(1.40,3.69),P<0.001]。结论中国大型ICCU中AKI较为常见,更可能发生于年龄较大、合并慢性疾病更复杂以及急性疾病严重程度更重的患者;AKI与院内复合终点事件以及短期随访生存率独立相关。

Objective To explore the clinical characteristics,in-hospital outcomes,and short-term survival of patients with acute kidney injury(AKI)in a large non-surgical cardiac intensive care unit(ICCU)in China.Methods Patients who had been admitted to the ICCU of the Department of Cardiology,West China Hospital of Sichuan University between June 2016 and May 2017 were retrospectively included.The diagnosis and staging of AKI were based on the Kidney Disease:Improving Global Outcomes criteria.The in-hospital outcomes were the composite of all-cause death or discharge against medical advice under extremely critical conditions.Patients without in-hospital composite outcomes were followed up to determine whether all-cause death occurred during the study period.The association of AKI with in-hospital composite outcomes or short-term survival was analyzed.Normally distributed quantitative data were expressed as mean±standard deviation,and non-normally distributed quantitative data were expressed as median(lower quartile,upper quartile).Results This study included 2083 patients,with an average age of(65.5±14.6)years old,and 681(32.7%)were women.The prevalence rate of AKI was 15.0%(312/2083)(stage 1:6.9%;stage 2:4.9%;stage 3:3.2%;respectively).Compared with patients without AKI,patients with AKI were older[(68.9±14.3)vs.(64.9±14.6)years old,P<0.001],had a higher Charles Comorbidity Index[4.0(3.0,6.0)vs.2.0(1.0,3.0),P<0.001]and a greater Oxford Acute Illness Severity Score[32.0(24.0,41.2)vs.21.0(16.0,26.0),P<0.001].The incidence of in-hospital composite endpoint events was 8.4%(174/2083).Multiple logistic regression analysis showed that as the AKI stage increased,the risk of in-hospital composite endpoint events was higher[AKI stage 1 vs.no AKI:odds ratio(OR)=1.13,95%confidence interval(CI)(0.57,2.24);AKI stage 2 vs.no AKI:OR=2.21,95%CI(1.08,4.51);AKI stage 3 vs.no AKI:OR=10.88,95%CI(4.50,26.34);P for trend<0.001].The patients without in-hospital composite endpoint events were followed up for a median time of 13.5(10.7,16.6)months,and the all-cause mortality rate was 5.5%(105/1909).Multiple Cox regression analysis showed that AKI was independently associated with all-cause death[hazard ratio=2.27,95%CI(1.40,3.69),P<0.001].Conclusions AKI is common in the large ICCU in China and is more likely to occur in older patients who have more significant chronic illness complexity and acute illness severity.Moreover,AKI is independently associated with the in-hospital composite endpoint events and short-term survival.