大面积烧伤患者发生早期急性肾损伤的危险因素分析

Analysis of risk factors of early acute kidney injury in patients with massive burn injuries

目的:探讨大面积烧伤患者发生早期急性肾损伤(AKI)的危险因素,为临床治疗提供参考。方法:选择2018年1月至2022年8月武汉大学同仁医院暨武汉市第三医院烧伤科收治的符合入选标准的201例成年大面积烧伤患者,其中男137例,女64例,年龄49(36,56)岁,烧伤总面积为70%(59.5%,85%)体表总面积,简明烧伤严重度指数(ABSI)评分49(37.5,62.9)分。根据伤后3 d内是否发生AKI将患者分为AKI组和非AKI组。采用单因素分析筛选可能影响AKI发生的相关因素,包括性别、年龄、致伤原因、基础疾病、伤后至入院时间、基础伤情、治疗情况等指标。数据分析采用两独立样本t检验、Mann-Whitney U检验、χ^(2)检验或Fisher确切概率法。结合单因素分析结果及临床意义,将指标纳入自变量,进行多因素Logistic回归分析,筛选出大面积烧伤患者发生早期AKI的独立危险因素,建立预测模型并计算模型的ROC曲线下面积。结果:共71例(35.3%)患者在伤后3 d内发生AKI。与非AKI组相比,AKI组患者年龄更大(P=0.013),男性(P=0.002)、电烧伤(P<0.001)、高血压(P=0.007)、吸入性损伤(P=0.010)的百分比更高,烧伤总面积(P<0.001)、Ⅲ度烧伤面积(P<0.001)更大,ABSI评分更高(P<0.001),首次手术出血量更大(P=0.002),且切开减张(P<0.001)、气管切开(P<0.001)、机械通气(P<0.001)的百分比更高,入院时部分化验指标(包括尿素氮、肌酐、胱抑素C、乳酸、红细胞压积、血小板总数)更高(P<0.05),伤后3 d内去甲肾上腺素(P=0.019)、呋塞米(P<0.001)用药百分比更高。根据单因素分析结果及变量的临床意义,筛选出10个可能的影响因素为自变量,进行Logistic回归分析,结果显示性别、年龄、电烧伤、ABSI评分、气管切开、入院时血乳酸值是大面积烧伤患者发生早期AKI的独立危险因素。经多因素Logistic回归分析建立大面积烧伤患者发生早期AKI的预测模型,方程为Logit(P)=-7.021+1.339×男性+0.047×年龄+1.990×电烧伤+1.543×ABSI评分+1.475×气管切开+0.185×入院时血乳酸值,该模型的ROC曲线下面积为0.855(95%CI:0.800~0.910,P<0.001),灵敏度为0.823,特异度为0.737。结论:男性、年龄偏大、电烧伤、ABSI评分偏高、气管切开、入院时血乳酸值偏高的大面积烧伤患者发生早期AKI的可能性更大。

Objective To explore the risk factors of early acute kidney injury(AKI)in patients with massive burn injuries and provide reference for clinical treatment.Methods A total of 201 adult inpatients with massive burn injuries who met the inclusion criteria in Department of Burns,Tongren Hospital of Wuhan University&Wuhan Third Hospital from January 2018 to August 2022 were entrolled,including 137 males and 64 females,aged 49(36,56)years old,the total burn area was 70%(59.5%,85%)of the total body surface area(TBSA),and abbreviated burn severity index(ABSI)score was 49(37.5,62.9).The patients were divided into AKI group and non-AKI group according to whether AKI occurred within 3 days after injury.Univariate analysis was used to screen the factors that might affect the occurrence of AKI,including gender,age,cause of injury,basic diseases,the time from injury to admission,features of basic injuries,and treatment.Data were statistically analyzed with independent sample t test,Mann-Whitney U test,chi-square test or Fisher exact probability method.The multivariate Logistic regression analysis was conducted to screen the independent risk factors for early AKI in patients with massive burn injuries,and the inclusion of factors combined with univariate analysis results and clinical significance.A prediction model was established by the outcome of multivariate Logistic regression and the area under the ROC curve of the model was calculated.Results AKI occurred in 71 patients(35.3%)within 3 days after injury.In comparison to the non-AKI group,the AKI group had the older age(P=0.013),higher percentage of males(P=0.002),electric burns(P<0.001),hypertension(P=0.007),and inhalation injury(P=0.010),larger total burn area(P<0.001)and full-thickness burn area(P<0.001),higher ABSI score(P<0.001),more blood lost in the first operation(P=0.002),higher percentage of incision and tension reduction of burn eschar(P<0.001),tracheotomy(P<0.001)and mechanical ventilation(P<0.001);the AKI group had higher value of some serum parameters on admission,including urea nitrogen,creatinine,cystatin C,lactate,hematocrit,and total platelet count(P<0.05);the AKI group had higher usage rate of norepinephrine(P=0.019),and furosemide(P<0.001)injection within 3 days after injury.According to the results of univariate analysis and the clinical significance of the variables,10 possible predictive variables were screened out and multivariate Logistic regression analysis was performed.The results showed that gender,age,electric burn,ABSI score,tracheotomy,and lactate on admission were independent risk factors for early AKI in patients with massive burn injuries.The predictive model for early AKI in massive burn patients was established through multivariate Logistic regression analysis:Logit(P)=-7.021+1.339×male+0.047×age+1.990×electric burns+1.543×ABSI score+1.475×tracheotomy+0.185×lactate value on admission,and the area under the ROC curve of the model was 0.855(95%CI:0.800~0.910,P<0.001),with sensitivity and specificity of 0.823 and 0.737,respectively.Conclusion The elderly male massive burn patients with electric burn,high ABSI score,tracheotomy,and high lactate on admission are more likely to occur early AKI.