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中华危重症医学杂志(电子版) ›› 2018, Vol. 11 ›› Issue (06) : 366 -371. doi: 10.3877/cma.j.issn.1674-6880.2018.06.002

所属专题: 文献

论著

脓毒性休克致急性肾损伤患者的危险因素分析
刘晓原1, 裴源源1, 朱继红1,()   
  1. 1. 100044 北京,北京大学人民医院急诊科
  • 收稿日期:2018-07-10 出版日期:2018-12-01
  • 通信作者: 朱继红
  • 基金资助:
    北京大学人民医院研究与发展基金项目(RDY2018-15)

Analysis of risk factors in patients with acute kidney injury caused by septic shock

Xiaoyuan Liu1, Yuanyuan Pei1, Jihong Zhu1,()   

  1. 1. Department of Emergency Medicine, Peking University People's Hospital, Beijing 100044, China
  • Received:2018-07-10 Published:2018-12-01
  • Corresponding author: Jihong Zhu
  • About author:
    Corresponding author: Zhu Jihong, Email:
引用本文:

刘晓原, 裴源源, 朱继红. 脓毒性休克致急性肾损伤患者的危险因素分析[J/OL]. 中华危重症医学杂志(电子版), 2018, 11(06): 366-371.

Xiaoyuan Liu, Yuanyuan Pei, Jihong Zhu. Analysis of risk factors in patients with acute kidney injury caused by septic shock[J/OL]. Chinese Journal of Critical Care Medicine(Electronic Edition), 2018, 11(06): 366-371.

目的

研究脓毒性休克患者急性肾损伤(AKI)的发生率及病死率,并寻找其危险因素。

方法

回顾性研究2015年6月至2016年6月北京大学人民医院急诊科及重症监护室符合脓毒性休克诊断标准的294例患者,根据是否发生AKI,将294例患者分为AKI组(194例)及非AKI组(100例)。比较两组患者的一般资料,采用Logistic回归分析脓毒性休克致AKI患者的危险因素。

结果

本研究中脓毒性休克患者AKI的发生率为66.0%(194 / 294)。AKI组患者院内病死率较非AKI组显著升高(70.6% vs. 22.0%,χ2 = 26.327,P < 0.001)。AKI组及非AKI组患者年龄[60(43,73)岁vs. 43(28,67)岁,Z = 2.095,P = 0.036]、平均动脉压[(60 ± 14)mmHg vs.(67 ± 16)mmHg,t = 2.175,P = 0.032]、心率[(124 ± 23)次/ min vs.(112 ± 23)次/ min,t = 2.369,P = 0.020]、氧合指数[(166 ± 113)mmHg vs.(254 ± 150)mmHg,t = 2.820,P = 0.003]、乳酸[(4.6 ± 3.0)mmol / L vs.(2.5 ± 1.9)mmol / L,t = 3.026,P = 0.006]、序贯器官衰竭估计(SOFA)评分[(13 ± 4)分vs.(8 ± 4)分,t = 4.936,P < 0.001]、室性及室上性心律失常(32.5% vs. 8.0%,χ2 = 4.334,P = 0.037)、C反应蛋白[(210 ± 104)mg / L vs.(145 ± 71)mg / L,t = 2.923,P = 0.005]、天门冬氨酸氨基转移酶[92(41,345)U / L vs. 36(18,65)U / L,Z = 3.794,P < 0.001]、血肌酐[(239 ± 164)μmol / L vs.(71 ± 22)μmol / L,t = 5.729,P < 0.001]、血尿素氮[(26 ± 16)mol / L vs.(10 ± 8)mol / L,t = 5.212,P < 0.001]、肾小球滤过率[(38 ± 29)mL·min-1·1.73 m-2 vs.(101 ± 28)mL·min-1·1.73 m-2t = 9.944,P < 0.001]、肌钙蛋白I [0.39(0.08,1.60)μg / L vs. 0.05(0.01,0.20)μg / L,Z = 3.437,P = 0.001]、D-二聚体[3 538(1 348,9 310)μg / L vs. 2 333(653,4 169)μg / L,Z = 2.458,P = 0.049]、去甲肾上腺素(66.0% vs. 39.0%,χ2 = 1.309,P = 0.007)、日呋塞米最大使用剂量[40(20,98)mg vs. 10(0,20)mg,Z = 3.992,P < 0.001]、机械通气(59.8% vs. 25.0%,χ2 = 0.145,P = 0.001)、血液净化(12.9% vs. 0%,χ2 = 76.945,P = 0.030)及深静脉置管(67.5% vs. 47.0%,χ2 = 4.400,P = 0.041)等比较,差异均有统计学意义。将上述指标纳入Logistic回归分析,结果显示,平均动脉压[OR = 1.035,95%CI(0.997,1.075),P = 0.032]、乳酸[OR = 1.065,95%CI(0.982,1.102),P = 0.028]、SOFA评分[OR = 1.232,95%CI(1.013,1.455),P = 0.049]、机械通气[OR = 1.942,95%CI(1.461,4.191),P = 0.036]、日呋塞米最大剂量[OR = 1.123,95%CI(0.884,1.793),P = 0.013]是脓毒症致AKI的危险因素。

结论

平均动脉压、乳酸、SOFA评分、机械通气及日呋塞米最大剂量的检测有助于临床早期识别脓毒性休克发生AKI的高危患者,从而早期采取预防措施。

Objective

To study the incidence and mortality of acute kidney injury (AKI) in patients with septic shock and to find out its risk factors.

Methods

Totally 294 patients who met the criteria for diagnosis of septic shock in Departments of Emergency Medicine and Intensive Care Unit of Peking University People's Hospital from June 2015 to June 2016 were included in the retrospective study. According to the occurrence of AKI, 294 patients were divided into the AKI group (194 cases) and non-AKI group (100 cases). The general data of the two groups were compared and the risk factors of AKI patients with septic shock were analyzed by Logistic regression analysis.

Results

In this study, the incidence of AKI in septic shock patients was 66.0% (194 / 294). The nosocomial mortality was significantly higher in the AKI group than in non-AKI group (70.6% vs. 22.0%, χ2 = 26.327, P < 0.001). The age [60 (43, 73) years old vs. 43 (28, 67) years old, Z = 2.095, P = 0.036], mean arterial pressure [(60 ± 14) mmHg vs. (67 ± 16) mmHg, t = 2.175, P = 0.032], heart rate [(124 ± 23) beats / min vs. (112 ± 23) beats / min, t = 2.369, P = 0.020], oxygenation index [(166 ± 113) mmHg vs. (254 ± 150) mmHg, t = 2.820, P = 0.003), lactic acid [(4.6 ± 3.0) mmol / L vs. (2.5 ± 1.9) mmol / L, t = 3.026, P = 0.006)], sequential organ failure assessment (SOFA) score [(13 ± 4) vs. (8 ± 4), t = 4.936, P < 0.001)], ventricular and supraventricular arrhythmias (32.5% vs. 8.0%, χ2 = 4.334, P = 0.037), C-reactive protein [(210 ± 104) mg / L vs. (145 ± 71) mg / L, t = 2.923, P = 0.005], aspartate aminotransferase [92 (41, 345) U / L vs. 36 (18, 65) U / L, Z = 3.794, P < 0.001], serum creatinine [(239 ± 164) μmol / L vs. (71 ± 22) μmol / L, t = 5.729, P < 0.001], blood urea nitrogen [(26 ± 16) mol / L vs. (10 ± 8) mol / L, t = 5.212, P < 0.001], glomerular filtration rate [(38 ± 29) mL·min-1·1.73m-2 vs. (101 ± 28) mL·min-1·1.73m-2, t = 9.944, P < 0.001], troponin I [0.39 (0.08, 1.60) μg / L vs. 0.05 (0.01, 0.20) μg / L, Z = 3.437, P = 0.001), D-dimer [3 538 (1 348, 9 310) μg / L vs. 2 333 (653, 4 169) μg / L, Z = 2.458, P = 0.049], norepinephrine (66.0% vs. 39.0%, χ2 = 1.309, P = 0.007), daily maximum dose of furosemide [40 (20, 98) mg vs. 10 (0, 20) mg, Z = 3.992, P < 0.001], mechanical ventilation (59.8% vs. 25.0%, χ2 = 0.145, P = 0.001), blood purification (12.9% vs. 0%, χ2 = 76.945, P = 0.030) and deep vein catheterization (67.5% vs. 47.0%, χ2 = 4.400, P = 0.041) were statistically significantly different in the AKI group and non-AKI group. Logistic regression analysis showed that the mean arterial pressure [OR = 1.035, 95%CI (0.997, 1.075), P = 0.032], lactic acid [OR = 1.065, 95%CI (0.982, 1.102), P = 0.028], SOFA score [OR = 1.232, 95%CI (1.013, 1.455), P = 0.049)], mechanical ventilation [OR = 1.942, 95%CI (1.461, 4.191), P = 0.036] and daily maximum dose of furosemide [OR = 1.123, 95%CI (0.884, 1.793), P = 0.013)] were risk factors for septic AKI.

Conclusion

The mean arterial pressure, lactic acid, SOFA score, mechanical ventilation and daily maximum dose of furosemide are helpful in early identification of high-risk patients with AKI in septic shock, so that early preventive measures can be taken.

表1 两组脓毒性休克患者基线资料比较[例(%)]
表2 两组脓毒性休克患者住院期间一般情况评估( ± s
表3 两组脓毒性休克患者实验室检查指标比较( ± s
组别 例数 白细胞计数[×109/L,MP25P75)] 血红蛋白计数(g/L) 血小板计数[×109/L,MP25 P75)] 中性粒细胞百分比(%) C反应蛋白(mg/L) 谷氨酸转氨酶[U/L, MP25 P75)] 天门冬氨酸氨基转移酶[U/L, MP25, P75)] 白蛋白(g/ L) 总胆红素[μmol/L,MP25 P75)]
AKI组 194 15.8(1.6,26.2) 89 ± 24 31(11,86) 73 ± 33 210 ± 104 62(24,206) 92(41,345) 28 ± 6 39(20,66)
非AKI组 100 12.4(1.9,24.8) 92 ± 20 43(15,116) 72 ± 32 145 ± 71 38(19,82) 36(18,65) 30 ± 6 23(15,50)
t/Z/χ2 ? 0.487 0.758 1.105 0.184 2.923 1.955 3.794 1.585 1.919
P ? 0.626 0.450 0.269 0.854 0.005 0.051 < 0.001 0.116 0.055
组别 例数 血糖(mmol/L) 血肌酐(μmol/L) 血尿素氮(mmol/ L) 肾小球滤过率(mL · min-1 · 1.73 m-2) 降钙素原[μg/L,MP25 P75)] 肌钙蛋白I [g/ L,MP25 P75)] B型脑钠肽[ng/ L,MP 25 P75)] 凝血酶原时间(s)
AKI组 194 9 ± 4 239 ± 164 26 ± 16 38 ± 29 30.0(10.8,86.2) 0.39(0.08,1.60) 969(356,2 383) 20 ± 13
非AKI组 100 9 ± 7 71 ± 22 10 ± 8 101 ± 28 20.1(1.7,25.0) 0.05(0.01,0.20) 823(322,1 331) 17 ± 6
t/Z/χ2 ? 0.433 5.729 5.212 9.944 0.337 3.437 1.398 1.127
P ? 0.666 < 0.001 < 0.001 < 0.001 0.763 0.001 0.162 0.263
组别 例数 活化部分凝血活酶时间(s) D-二聚体(μg/ L, MP 25P75)] 血培养[例(%)] 其他培养[例(%)] 培养提示为CRE[例(%)] 真菌相关检查[例(%)] 结核相关检查[例(%)] 病毒相关检查[例(%)] 左室射血分数(%)
AKI组 194 47 ± 20 3 538(1 348,9 310) 69(35.6) 88(45.4) 22(11.3) 72(37.1) 2(1.0) 9(4.6) 67 ± 31
非AKI组 100 42 ± 14 2 333(653,4 169) 50(50.0) 31(31.0) 12(12.0) 44(44.0) 0(0) 7(7.0) 68 ± 7
t/Z/χ2 ? 1.349 2.458 47.036 26.855 126.618 7.655 72.782 29.582 0.376
P ? 0.181 0.049 0.392 0.110 0.448 0.635 0.258 0.896 0.708
表4 两组脓毒性休克患者药物及器械辅助治疗比较[例(%)]
表5 脓毒性休克致AKI患者危险因素Logistic回归分析
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