危重症患者CRRT过程中低磷血症发生与预后的回顾性研究

A retrospective study on hypophosphatemia of critically ill patients during CRRT

目的了解危重症患者连续性肾脏替代治疗(CRRT)过程中相关低磷血症的发生率,探索其发生的危险因素,并评估补磷治疗的临床获益。方法选取西安交通大学第一附属医院2017年1月1日至2018年12月31日期间接受CRRT的451例危重症患者为研究对象,根据血清磷水平是否<0.81 mmol/L将入选的患者分为低磷血症组(297例)与非低磷血症组(154例),收集2组患者的年龄、性别、合并基础疾病、主要诊断、临床评分、CRRT上机目的、上机前电解质水平、住院时间、预后情况等基础及临床信息,分析低磷血症发生和发展可能的危险因素;进一步将发生低磷血症的患者根据是否补磷进行二次分类,分析补磷治疗对患者的住院时间及预后有无改善。结果接受CRRT的危重症患者低磷血症的发生率为65.85%,女性(OR=2.484,95%CI:1.413~4.367)、CRRT上机前较低的血磷水平(OR=0.469,95%CI:0.326~0.673)和CRRT上机治疗总时间较长(OR=1.054,95%CI:1.038~1.070)的患者更容易发生低磷血症,女性患者(P=0.014)、泌尿系统基础疾病(P=0.012)、主要诊断为泌尿系统疾病(P=0.013)、上机前血磷水平更低(P=0.019)、更长的CRRT上机治疗总时间(P<0.001)、ICU住院时间(P<0.001)均与患者出现更为严重的低磷血症相关。补磷组与非补磷组2组患者住院期间、出院30 d、出院90 d的病死率差异无统计学意义,但是补磷组患者在CRRT期间接受磷酸盐补充后,其下机后首次血磷值较CRRT期间血磷平均值均有提高[(0.11±0.50)mmol/L]。结论危重症患者CRRT期间低磷血症的发生率较高,可采用性别与CRRT治疗总时间联合预测CRRT相关低磷血症的发生,对于发生低磷血症的患者,可以给予适当的补磷治疗。

Objective To investigate the morbidity of continuous renal replacement therapy(CRRT)-related hypophosphatemia in critically ill patients,risk factors for CRRT-related hypophosphatemia and clinical benefits of phosphorus supplementation.Methods A total of 451 critically ill patients who received CRRT in the First Affiliated Hospital of Xi'an Jiaotong University from January 1,2017 to December 31,2018 were recruited.According to whether serum phosphorus level less than 0.81 mmol/L,the patients were divided into hypophosphatemia group(n=297)and non-hypophosphatemia group(n=154).Basic clinical information of patients were collected,including age,gender,cormorbidities,major diagnosis,clinical scoring,indication for CRRT,electrolytes before CRRT,length of hospital stay,prognosis,and possible risk factors for hypophosphatemia were analyzed.Patients with hypophosphatemia were further subdivided into subgroups according to whether or not receiving phosphorus supplementation,and were analyzed on length of hospital stay and prognosis.Results The incidence of CRRT-related hypophosphatemia in critically ill patients was 65.85%.Female(OR=2.484,95%CI:1.413-4.367),patients with lower blood phosphorus levels before CRRT[1.31(0.93,1.82)mmol/L vs 1.68(1.35,2.20)mmol/L,OR=0.469,95%CI:0.326-0.673]and patients with longer duration on CRRT[66.3(39.3,131.8)h vs 24.0(16.0,34.0)h,OR=1.054,95%CI:1.038-1.070]may be more likely to develop hypophosphatemia.Female patients(P=0.014),complicated with urologic diseases(P=0.012),primary diagnosis as urologic disease(P=0.013),lower blood phosphorus level before CRRT[mild 1.50(1.10,2.04)mmol/L vs severe 1.25(0.83,1.73)mmol/L,P=0.019],longer duration of CRRT[mild 45.38(29.50,71.10)days vs severe 116.50(57.70,194.80)days,P<0.001],and length of ICU stay[mild 0(0,5)days vs severe 11(5,21)days,P<0.001]may be associated with more severe hypophosphatemia.In terms of benefits from phosphorus supplementation,although there was no statistically difference in hospital mortality,mortality at 30 days after discharge,and mortality at 90 days after discharge between these two groups,blood phosphorus level at the end of CRRT in phosphorus supplementation group did increase[(0.11±0.50)mmol/L]compared with average blood phosphorus level during CRRT.Conclusion The incidence of CRRT-related hypophosphatemia is high in critically ill patients.Gender and total duration of CRRT can be characteristics combined to predict the occurrence of CRRT-related hypophosphatemia.For patients developing hypophosphatemia during CRRT,phosphorus can be supplemented appropriately.