脓毒症伴急性肾损伤患者连续性肾脏替代治疗时机的探讨

doi:10.3877/cma.j.issn.1674-6880.2016.03.002

目的

探讨脓毒症伴急性肾损伤（AKI）患者连续性肾脏替代治疗（CRRT)最佳开始时机。

方法

选择浙江省人民医院ICU在2011年1月至2015年1月期间收治的脓毒症伴AKI并接受CRRT治疗的112例成年患者，根据CRRT治疗前的KDIGO-AKI分期，将处于AKI-1期或2期的患者归于早期组（52例），而AKI-3期的患者则归于晚期组（60例）。比较两组患者的急性病生理学和长期健康评价（APACHE）Ⅱ评分、序贯器官衰竭评分（SOFA）、平均动脉压、乳酸水平、WBC、血红蛋白、血小板计数、机械通气时间、ICU住院时间、28 d生存率、住院病死率情况。同时采用Kaplan-Meier生存分析法绘制早期组和晚期组患者的生存曲线，并用Log-Rank检验进行比较分析。

结果

两组患者CRRT治疗前的APACHEⅡ评分、平均动脉压、乳酸水平、血小板计数等方面比较，差异均无统计学意义（P均>0.05），与早期组患者比较，晚期组患者的SOFA评分[（9.6 ± 4.3）分vs.（7.4 ± 2.9）分，t=3.171，P=0.002]、WBC[（15 ± 8）× 10⁹/L vs.（12 ± 9）× 10⁹/L，t=2.273，P=0.025]及住院病死率[70%（42/60）vs. 50.0%（26/52），χ²=4.672，P=0.031]更高，血红蛋白含量[（89 ± 25）g/L vs.（100 ± 27）g/L，t=2.107，P=0.037]、28 d生存率[40.0%（24/60）vs. 61.54%（32/52），χ²=5.169，P=0.023]更低。而两组患者的平均机械通气时间和ICU住院时间比较，差异均无统计学意义（P均>0.05）。Kaplan-Meier生存曲线提示，早期组患者的生存率高于晚期组患者（χ²=12.169，P<0.001）。

结论

脓毒症伴AKI患者病死率高，CRRT的最佳介入时机应早于患者肾功能进展至AKI-3期时。

关键词: 脓毒症, 急性肾损伤, 连续性肾脏替代治疗, 时机

Objective

To explore the optimal timing for continuous renal replacement therapy (CRRT) in sepsis patients with acute kidney injury (AKI).

Methods

A total of 112 sepsis patients with AKI treated with CRRT in ICU of Zhejiang Provincial People's Hospital from January 2011 to January 2015 were divided into the early CRRT group (AKI-stage 1 or stage 2, 52 cases) and late CRRT group (AKI-stage 3, 60 cases) according to their Kidney Disease: Improving Global Outcomes (KDIGO)-AKI stage before initiation of CRRT. The acute physiology and chronic health evaluation (APACHE) Ⅱ score, sequential organ failure (SOFA) score, mean arterial pressure, serum lactate, WBC, hemoglobin, blood platelet count, duration of mechanical ventilation, length of ICU stay, 28 d survival rate and fatality rate of inpatient were compared between the two groups. Kaplan-Meier curves obtained with the Log-rank test were plotted to demonstrate the differences in patients' survival between the two groups.

Results

There were no significant differences between the two groups in APACHE Ⅱ score, mean arterial pressure, serum lactate and blood platelet count before CRRT (all P>0.05). In the late CRRT group, the SOFA score [(9.6 ± 4.3) vs. (7.4 ± 2.9), t=3.171, P=0.002], WBC [(15 ± 8) × 10⁹/L vs. (12 ± 9) × 10⁹/L, t=2.273, P=0.025] and fatality rate of inpatient [70% (42/60) vs. 50.0% (26/52), χ²=4.672, P=0.031] were much higher, and hemoglobin [(89 ± 25) g/L vs. (100 ± 27) g/L, t=2.107, P=0.037], 28 d survival rate [40.0% (24/60) vs. 61.54% (32/52), χ²=5.169, P=0.023] were much lower than those in the early CRRT group. However, the duration of mechanical ventilation and length of ICU stay showed no significant differences between the two groups (all P>0.05). Furthermore, the Log-rank test of Kaplan-Meier curves also showed that survival rate in the early CRRT group was better than that in the late RRT group (χ²=12.169, P<0.001).

Conclusion

The mortality is really high in patients with sepsis-associated AKI, and the optimal timing of initiating CRRT may predate in patients with early renal progress to AKI-3 phase.

Key words: Sepsis, Acute kidney injury, Continuous renal replacement therapy, Timing

表1 2012年改善全球肾脏病预后组织急性肾损伤分级标准

分级	血清肌酐	尿量
1	基础值的1.5 ~ 1.9倍或增加≥ 0.3 mg/dl（≥ 26.5 μmol/L）	< 0.5 ml·kg^-1·h^-1持续6 ~ 12 h
2	基础值的2.0 ~ 2.9倍	< 0.5 ml·kg^-1·h^-1至少12 h
3	基础值的3.0倍及以上或肌酐升高至≥ 4.0 mg/dl (≥ 353.6 μmol/L)或开始进行肾脏替代治疗或年龄< 18岁时，估算肾小球滤过率下降至< 35 ml·min^-1· 1.73 m^-2	< 0.3 ml·kg^-1·h^-1至少24 h或无尿至少12 h

表1 2012年改善全球肾脏病预后组织急性肾损伤分级标准

分级	血清肌酐	尿量
1	基础值的1.5 ~ 1.9倍或增加≥ 0.3 mg/dl（≥ 26.5 μmol/L）	< 0.5 ml·kg^-1·h^-1持续6 ~ 12 h
2	基础值的2.0 ~ 2.9倍	< 0.5 ml·kg^-1·h^-1至少12 h
3	基础值的3.0倍及以上或肌酐升高至≥ 4.0 mg/dl (≥ 353.6 μmol/L)或开始进行肾脏替代治疗或年龄< 18岁时，估算肾小球滤过率下降至< 35 ml·min^-1· 1.73 m^-2	< 0.3 ml·kg^-1·h^-1至少24 h或无尿至少12 h

表2 脓毒症伴急性肾损伤患者CRRT治疗前的临床资料的比较（±s）

组别	例数	APACHEⅡ评分（分）	SOFA评分（分）	平均动脉压（mmHg）	WBC（× 10⁹/L）	血红蛋白（g/L）	血小板计数（× 10⁹/L）	乳酸（mmol/L）
早期组	52	19 ± 7	7.4 ± 2.9	86 ± 22	12 ± 9	100 ± 27	144 ± 75	3.0 ± 2.3
晚期组	60	20 ± 8	9.6 ± 4.3	92 ± 20	15 ± 8	89 ± 25	161 ± 116	3.2 ± 2.7
t/χ²值	?	1.007	3.171	1.737	2.273	2.107	0.917	0.328
P值	?	0.316	0.002	0.085	0.025	0.037	0.361	0.743

表2 脓毒症伴急性肾损伤患者CRRT治疗前的临床资料的比较（±s）

组别	例数	APACHEⅡ评分（分）	SOFA评分（分）	平均动脉压（mmHg）	WBC（× 10⁹/L）	血红蛋白（g/L）	血小板计数（× 10⁹/L）	乳酸（mmol/L）
早期组	52	19 ± 7	7.4 ± 2.9	86 ± 22	12 ± 9	100 ± 27	144 ± 75	3.0 ± 2.3
晚期组	60	20 ± 8	9.6 ± 4.3	92 ± 20	15 ± 8	89 ± 25	161 ± 116	3.2 ± 2.7
t/χ²值	?	1.007	3.171	1.737	2.273	2.107	0.917	0.328
P值	?	0.316	0.002	0.085	0.025	0.037	0.361	0.743

图1 两组脓毒症伴急性肾损伤患者的Kaplan-Meier生存曲线

[1]	Mandelbaum T, Scott DJ, Lee J, et al.Outcome of critically ill patients with acute kidney injury using the Acute Kidney Injury Network criteria[J].Crit Care Med, 2011, 39 (12): 2659-2664.
[2]	Murugan R, Kellum JA.Acute kidney injury: what's the prognosis?[J].Nat Rev Nephrol, 2011, 7 (4): 209-217.
[3]	Kellum JA, Sileanu FE, Murugan R, et al.Classifying AKI by urine output versus serum creatinine level[J].J Am Soc Nephrol, 2015, 26 (9): 2231-2238.
[4]	Uchino S, Kellum JA, Bellomo R, et al.Acute renal failure in critically ill patients: a multinational, multicenter study[J].JAMA, 2005, 294 (7): 813-818.
[5]	Kellum JA, Chawla LS, Keener C, et al.The effects of alternative resuscitation strategies on acute kidney injury in patients with septic shock[J].Am J Respir Crit Care Med, 2016, 193 (3): 281-287.
[6]	Levy MM, Fink MP, Marshall JC, et al.2001 SCCM/ESICM/ACCP/ATS/SIS international sepsis definitions conference[J].Crit Care Med, 2003, 31 (4): 1250-1256.
[7]	Kellum JA, Lameire N, KDIGO AKI Guideline Work Group.Diagnosis, evaluation, and management of acute kidney injury: a KDIGO summary (Part 1)[J].Crit Care, 2013, 17 (1): 204.
[8]	Bagshaw SM, Uchino S, Bellomo R, et al.Septic acute kidney injury in critically ill patients: clinical characteristics and outcomes[J].Clin J Am Soc Nephrol, 2007, 2 (3): 431-439.
[9]	Singer M, Deutschman CS, Seymour CW, et al.The third international consensus definitions for sepsis and septic shock (sepsis-3)[J].JAMA, 2016, 315 (8): 801-810.
[10]	Bagshaw SM, George C, Bellomo R.Early acute kidney injury and sepsis: a multicentre evaluation[J].Crit Care, 2008, 12 (2): R47.
[11]	王黎明，柴艳芬，董佳月，等.连续性血液净化治疗脓毒症临床疗效的Meta分析[J].中华危重症医学杂志：电子版，2014，7（5）：302-307.
[12]	Kellum JA, Kong L, Fink MP, et al.Understanding the inflammatory cytokine response in pneumonia and sepsis: results of the genetic and inflammatory markers of sepsis(GenIMS) study[J].Arch Intern Med, 2007, 167 (15): 1655-1663.
[13]	Peng Z, Pai P, Han-Min W, et al.Evaluation of the effects of pulse high-volume hemofiltration in patients with severe sepsis: a preliminarystudy[J].Int J Artif Organs, 2010, 33 (8): 505-511.
[14]	De Vriese AS, Colardyn FA, Philippe JJ, et al.Cytokine removal during continuous hemofiltration in septic patients[J].J Am Soc Nephrol, 1999, 10 (4):846-853.
[15]	De Vriese AS, Vanholder RC, Pascual M, et al.Can inflammatory cytokines be removed efficiently by continuous renal replacement therapies?[J].Intensive Care Med, 1999, 25 (9): 903-910.
[16]	Piccinni P, Dan M, Barbacini S, et al.Early iso-volaemic haemofiltration in oliguric patients with septic shock[J].Intensive Care Med, 2006, 32 (1): 80-86.
[17]	Gettings LG, Reynolds HN, Scalea T.Outcome in post-traumatic acute renal failure when continuous renal replacement therapy is applied early vs. late[J].Intensive Care Med, 1999, 25 (8): 805-813.
[18]	Liu KD, Himmelfarb J, Paganini E, et al.Timing of initiation of dialysis in critically ill patients with acute kidney injury[J].Clin J Am Soc Nephrol, 2006, 1 (5): 915-919.
[19]	Page B, Vieillard-Baron A, Chergui K, et al.Early veno-venous haemodiafiltration for sepsis-related multi-ple organ failure[J].Crit Care, 2005, 9 (6): R755-R763.
[20]	韩静，邱俏檬，吴斌，等.脓毒症并发急性肾损伤患者临床特点及预后因素分析[J].中华危重症医学杂志：电子版，2014，7（1）：30-34.
[21]	Chou YH, Huang TM, Wu VC, et al.Impact of timing of renal replacement therapy initiation on outcome of septic acute kidney injury[J].Crit Care, 2011, 15 (3): R134.
[22]	卢年芳，郑瑞强，林华，等.连续性肾脏替代治疗严重感染合并急性肾损伤最佳时机的研究[J].中华医院感染学杂志，2012，22（14）：3055-3058.
[23]	Leite TT, Macedo E, Pereira SM, et al.Timing of renal replacement therapy initiation by AKIN classification system[J].Crit Care, 2013, 17 (2): R62.
[24]	Tian H, Sun T, Hao D, et al.The optimal timing of continuous renal replacement therapy for patients with sepsis-induced acute kidney injury[J].Int Urol Nephrol, 2014, 46 (10): 2009-2014.
[25]	Luo X, Jiang L, Du B, et al.A comparison of different diagnostic criteria of acute kidney injury in critically ill patients[J].Crit Care, 2014, 18 (4): R144.
[26]	孙丽君，孙海鹏，朱嘉琦，等.RIFLE、AKIN和KDIGO三种急性肾损伤诊断标准在心脏术后患者中的应用比较[J].中国中西医结合肾病杂志，2014，15（3）：211-215.

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Timing of continuous renal replacement therapy in sepsis patients with acute kidney injury

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Timing of continuous renal replacement therapy in sepsis patients with acute kidney injury