35例急性肾损伤的临床分析及预后转归
摘要
[背景和目的]
急性肾损伤(acute kidney injury, AKI)是临床常见急危重症之一,表现为肾功能急剧下降,短时间内血清肌酐进行性升高及尿量减少。2005年,急性肾损伤网络(acute kidney injury network, AKIN)于荷兰阿姆斯特丹制定了新的急性肾损伤共识。AKIN制定的AKI定义为：不超过3个月的肾脏功能或结构方面的异常,包括血、尿、组织检测或影像学方面的肾损伤标志物的异常。国外文献报道ARI发生率占住院患者2%。肾科住院患者13.3%,病死率高达30%～60%。
急性肾损伤是由多种病因导致的,是发生于各种临床情况之下的一种复杂的肾功能紊乱。目前,医学界普遍把AKI的病因分成肾前性、肾性及肾后性这三种。由于AKI常常和其他器官衰竭同时存在,或者作为多器官功能障碍综合征肾脏表现的一部分出现,给抢救和治疗带来很多难题。另一方面,由于AKI起病隐匿,进展急骤,病情多变,在加上临床认识不够,常常延误治疗时机,导致不良预后。临床对照研究已经证实不同年龄、不同病因AKI患者死亡率具有较大差异。因此,探讨AKI临床特点、病因、转归以及影响转归的因素,对AKI的预防和治疗具有重要意义。
基于以上背景,本研究以我院收治的AKI患者为研究对象,通过收集患者的病史资料、临床资料、化验检查资料及预后资料,分析AKI患者的年龄性别构成、病因分布、临床特点、预后转归以及影响预后的因素,以期巩固对AKI的认识,提高AKI的诊疗水平。
[方法]
收集我院2009年5月～2011年10月间收治AKI患者的临床病例资料,分析其病因及分布特征,并采用回归分析评估影响AKI预后的危险因素。
[结果]
1.研究共纳入35例患者,其中男性20例,女性15例,平均年龄46.32±15.7岁,≤40岁13例,41～59岁13例,≥60岁9例；内科患者25例(肾内科20例),外科7例,ICU2例,介入科1例；最长住院32天,最短住院9天,中位住院时间16天。
2.在病因分布上,肾前性AKI7例,占20%(7/35)；肾性AKI25例,占71%(25/35),肾性AKI中肾小球、肾血管性疾病者10例,占肾性因素的40%(10/25),肾小管间质性疾病者15例,占肾性因素的60%(15/25),主要病因为肾病综合征、药物、感染等因素；肾后性AKI3例,占8.6%(3/35),主要病因为结石、恶性肿瘤等梗阻性病因。本组患者中医源性AKI为8例,占总例数的22.86%(8/35),主要原因为手术、药物的不适当使用。
3.35例AKI患者出院时治愈15例(42.9%),好转14例(40%),死亡6例(17.1%)。
4.多因素Logistic回归分析显示年龄(≥60岁)、既往高血压病史、高钾血症、多器官脏器衰竭是影响预后的重要危险因素。
[结论]
1.AKI是临床的一个重要合并症；
2.本组资料中AKI病因以肾性因素为主(25/35),医源性因素也是AKI的重要原因之一；
3.年龄(≥60岁)、既往高血压病史、高钾血症、多器官脏器衰竭是影响AKI预后的危险因素。
(Background and Objective] Acute kidney injury (AKI) is one of the common clinical emergency and severe cases, which cause the rapid decline of kidney function,progressive increase of urea nitrogen and serum creatinine and decrease of eurine. In2005, acute kidney injury network (AKIN) formulated the new commen view of acute kidney injury in Amsterdam, Holland. The definition of AKI given by AKIN is:the abnormal performances of renal function or structure, which include the abnormal occurrences of blood, urine and tissue tests or the abnormal performance of renal injury maker. According to foreign literature, ARF incidence accounted for2%of hospitalized patients. The hospitalized patients of nephrology department were13.3%. The mortality rate was18.1%-69.6%.
Acute kidney injury is a complicated kidney malfunction that can happen in different kinds of clinical cases for various reasons. At present, the causes of AKI are divided into three aspects:renal, postrenal and prerenal. Because AKI is characterized by abrupt onset with varied dangerous conditions and is different to control, the delay in treatment may lead to a poor prognosis, and even threaten the lives of patients. Therefore, a comprehensive understanding of the risk factors, epidemiological status and the influence of the prognosis of the AKI, the improving awareness of the disease of the majority of clinicians, updating their knowledge to grasp early diagnosis, early treatment of the basic techniques for reducing the dangers of the disease are extremely significant. The main objects of this study are the hospitalized AKI patients in our department. This paper collects the patients' medical history data, clinical data, test data and prognosis data, analyzes the composition of patients' age and gender, pathogeny, clinical characteristics and prognostic factors, in order to increase the knowledge of AKI, improve the treatment of AKI and provide new ideas to prevent and cure AKI.
[Methods]Collected the clinical data of35AKI patients cases which were treated in our hospital during May,2009and October,2011, analyzed the causes, distribution characteristics, and risk factors of AKI, adopted the regression analysis to assess the risk factors of AKI prognosis.
[Results]
(1)35patients were male and15females, mean age46.32±15.7years old, the young group (≤40years)13cases, middle-aged group (41to60years)13cases, older group (≥61years old The)9cases;25cases (20cases of Nephrology, medical patients), seven cases of surgical, ICU2case, one cases of Interventional Radiology; average hospital stay was15.6±12.8days.
(2) in the distribution of the cause of prerenal of AKI7cases accounted for20%, mainly due to fluid loss, infection, heart dysfunction; renal25cases of AKI, accounting for71%; which glomerular and renal vascular10cases of disease, accounting for40%of renal factors,15cases of interstitial disease, accounting for60%of renal factors, the main cause of nephrotic syndrome, drugs, infections and other factors; renal nature of AKI after, accounting for8.6%, the main cause stones, cancer and other obstructive cause. Iatrogenic AKI eight cases,22.9%of the total number of cases, the main reason for the surgery, drugs, inappropriate use. Drug-induced AKI eight cases, accounting for22.9%, which the iatrogenic AKI6cases, two cases of patients with drug abuse. Acute renal failure in chronic kidney disease on the basis of six cases,17.1%of the total number of cases.5cases of renal biopsy.
(3)35cases of AKI Bank of renal replacement treatment of13cases (37.1%), hemodialysis,29cases (82.9%) were cured in six cases, improved in20cases,3cases died, and continuous renal replacement therapy in6cases (16.22%), which improved in one cases,5cases died. Discharged cured15cases (42.9%), improved in14cases (40%),6patients died (17.1%).
(4) Univariate analysis showed that gender, age, previous history of high blood pressure, urine output, hematuria MODS may be the prognosis of AKI impact Logistic regression analysis showed that age, previous history of hypertension, hyperkalemia, urine the amount of MODS factors affecting mortality.
[Conclusions]
1. AKI is still an important clinical complication which has higher occurrence rate.
2. The data of this paper shows that the main cause of AKI is MODS and the iatrogenic aspect is one of the important causes.
3. The risk factors are age (≥61years old), the past history of anti hypertension, hyperkalemia and multiple organ failure.
急性肾损伤(acute kidney injury, AKI)是临床常见急危重症之一,表现为肾功能急剧下降,短时间内血清肌酐进行性升高及尿量减少。2005年,急性肾损伤网络(acute kidney injury network, AKIN)于荷兰阿姆斯特丹制定了新的急性肾损伤共识。AKIN制定的AKI定义为：不超过3个月的肾脏功能或结构方面的异常,包括血、尿、组织检测或影像学方面的肾损伤标志物的异常。国外文献报道ARI发生率占住院患者2%。肾科住院患者13.3%,病死率高达30%～60%。
急性肾损伤是由多种病因导致的,是发生于各种临床情况之下的一种复杂的肾功能紊乱。目前,医学界普遍把AKI的病因分成肾前性、肾性及肾后性这三种。由于AKI常常和其他器官衰竭同时存在,或者作为多器官功能障碍综合征肾脏表现的一部分出现,给抢救和治疗带来很多难题。另一方面,由于AKI起病隐匿,进展急骤,病情多变,在加上临床认识不够,常常延误治疗时机,导致不良预后。临床对照研究已经证实不同年龄、不同病因AKI患者死亡率具有较大差异。因此,探讨AKI临床特点、病因、转归以及影响转归的因素,对AKI的预防和治疗具有重要意义。
基于以上背景,本研究以我院收治的AKI患者为研究对象,通过收集患者的病史资料、临床资料、化验检查资料及预后资料,分析AKI患者的年龄性别构成、病因分布、临床特点、预后转归以及影响预后的因素,以期巩固对AKI的认识,提高AKI的诊疗水平。
[方法]
收集我院2009年5月～2011年10月间收治AKI患者的临床病例资料,分析其病因及分布特征,并采用回归分析评估影响AKI预后的危险因素。
[结果]
1.研究共纳入35例患者,其中男性20例,女性15例,平均年龄46.32±15.7岁,≤40岁13例,41～59岁13例,≥60岁9例；内科患者25例(肾内科20例),外科7例,ICU2例,介入科1例；最长住院32天,最短住院9天,中位住院时间16天。
2.在病因分布上,肾前性AKI7例,占20%(7/35)；肾性AKI25例,占71%(25/35),肾性AKI中肾小球、肾血管性疾病者10例,占肾性因素的40%(10/25),肾小管间质性疾病者15例,占肾性因素的60%(15/25),主要病因为肾病综合征、药物、感染等因素；肾后性AKI3例,占8.6%(3/35),主要病因为结石、恶性肿瘤等梗阻性病因。本组患者中医源性AKI为8例,占总例数的22.86%(8/35),主要原因为手术、药物的不适当使用。
3.35例AKI患者出院时治愈15例(42.9%),好转14例(40%),死亡6例(17.1%)。
4.多因素Logistic回归分析显示年龄(≥60岁)、既往高血压病史、高钾血症、多器官脏器衰竭是影响预后的重要危险因素。
[结论]
1.AKI是临床的一个重要合并症；
2.本组资料中AKI病因以肾性因素为主(25/35),医源性因素也是AKI的重要原因之一；
3.年龄(≥60岁)、既往高血压病史、高钾血症、多器官脏器衰竭是影响AKI预后的危险因素。
(Background and Objective] Acute kidney injury (AKI) is one of the common clinical emergency and severe cases, which cause the rapid decline of kidney function,progressive increase of urea nitrogen and serum creatinine and decrease of eurine. In2005, acute kidney injury network (AKIN) formulated the new commen view of acute kidney injury in Amsterdam, Holland. The definition of AKI given by AKIN is:the abnormal performances of renal function or structure, which include the abnormal occurrences of blood, urine and tissue tests or the abnormal performance of renal injury maker. According to foreign literature, ARF incidence accounted for2%of hospitalized patients. The hospitalized patients of nephrology department were13.3%. The mortality rate was18.1%-69.6%.
Acute kidney injury is a complicated kidney malfunction that can happen in different kinds of clinical cases for various reasons. At present, the causes of AKI are divided into three aspects:renal, postrenal and prerenal. Because AKI is characterized by abrupt onset with varied dangerous conditions and is different to control, the delay in treatment may lead to a poor prognosis, and even threaten the lives of patients. Therefore, a comprehensive understanding of the risk factors, epidemiological status and the influence of the prognosis of the AKI, the improving awareness of the disease of the majority of clinicians, updating their knowledge to grasp early diagnosis, early treatment of the basic techniques for reducing the dangers of the disease are extremely significant. The main objects of this study are the hospitalized AKI patients in our department. This paper collects the patients' medical history data, clinical data, test data and prognosis data, analyzes the composition of patients' age and gender, pathogeny, clinical characteristics and prognostic factors, in order to increase the knowledge of AKI, improve the treatment of AKI and provide new ideas to prevent and cure AKI.
[Methods]Collected the clinical data of35AKI patients cases which were treated in our hospital during May,2009and October,2011, analyzed the causes, distribution characteristics, and risk factors of AKI, adopted the regression analysis to assess the risk factors of AKI prognosis.
[Results]
(1)35patients were male and15females, mean age46.32±15.7years old, the young group (≤40years)13cases, middle-aged group (41to60years)13cases, older group (≥61years old The)9cases;25cases (20cases of Nephrology, medical patients), seven cases of surgical, ICU2case, one cases of Interventional Radiology; average hospital stay was15.6±12.8days.
(2) in the distribution of the cause of prerenal of AKI7cases accounted for20%, mainly due to fluid loss, infection, heart dysfunction; renal25cases of AKI, accounting for71%; which glomerular and renal vascular10cases of disease, accounting for40%of renal factors,15cases of interstitial disease, accounting for60%of renal factors, the main cause of nephrotic syndrome, drugs, infections and other factors; renal nature of AKI after, accounting for8.6%, the main cause stones, cancer and other obstructive cause. Iatrogenic AKI eight cases,22.9%of the total number of cases, the main reason for the surgery, drugs, inappropriate use. Drug-induced AKI eight cases, accounting for22.9%, which the iatrogenic AKI6cases, two cases of patients with drug abuse. Acute renal failure in chronic kidney disease on the basis of six cases,17.1%of the total number of cases.5cases of renal biopsy.
(3)35cases of AKI Bank of renal replacement treatment of13cases (37.1%), hemodialysis,29cases (82.9%) were cured in six cases, improved in20cases,3cases died, and continuous renal replacement therapy in6cases (16.22%), which improved in one cases,5cases died. Discharged cured15cases (42.9%), improved in14cases (40%),6patients died (17.1%).
(4) Univariate analysis showed that gender, age, previous history of high blood pressure, urine output, hematuria MODS may be the prognosis of AKI impact Logistic regression analysis showed that age, previous history of hypertension, hyperkalemia, urine the amount of MODS factors affecting mortality.
[Conclusions]
1. AKI is still an important clinical complication which has higher occurrence rate.
2. The data of this paper shows that the main cause of AKI is MODS and the iatrogenic aspect is one of the important causes.
3. The risk factors are age (≥61years old), the past history of anti hypertension, hyperkalemia and multiple organ failure.
引文
1. Chertow GM, Burdick E, Honour M, et al. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients. [J]. J Am Soc Nephrol,2005, 16:3365-3370.
2. Bellomo R, Ronco C, Kellum JA, et al. Acute renal failure-definition, outcome measures, animal models, fluid therapy and information technology needs:the Second International Consensus Conference of the Acute Dialysis Quality Initiative (ADQI) Group. [J]. Crit Care 2004; 8(4):R204-R2I2.
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[3]李艳伟,夏天,李荣,等.急性肾损伤住院情况调查及危险因素发析[J].中华肾脏病杂志,2010,26(11)：866—867
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[12]张彤,梅林,急性肾衰竭100例临床分析,中华肾脏病杂志[J].2005,21(12)：732-736
[13]Hus CY,Ordonez JD,Chertow GM,et al. The risk of acute renal failure in patients with chronic kidney disease[J]. Kidney rnt,2008,74:101-107
[14]Goldberg R,Dennen P. Long-term outcomes of acute kidney injury. Adv Chronic Kidney Dis,2008,15:297-307
[15]Landoni G,Bkmdi-Zoccai GG,Tumlin JA, et al.Beneficial impact of fenoldopam in critically ill patients with or at risk for acute renal failure:a meta-analysis of randomized clinical trials[J]. Am J Kidney Dis.2007,49(1):56-68
[16]Bellomo R,Ronco C,Kellum JA,et al.Acute renal failure-definition,outcome measures,animal models,fluid therapy and information technology needsrthe Second International Consensus Conference of the Acute Dialysis Quality Initiative(ADQI)Group[J]. Crit Care.2004,8(4):R204-212
[17]Mehta RL,Pascual MT,Soroko S,et al. Spectrum of acute renal failure in the intensive care unit:thePICARD experience[J]. Kidney Int,2004,66(4):1613-1612
[18]FarleySJ. Acute kidney injury/acute renal failure:standardizing nomenclature, dedinitions and staging[J]. Nat Clin Pract Nephrol.2007,3(8):405
[19]Brzin J, Popovic T, Turk V. Human cystatin, a new protein inhibitor of cysteine proteinases [J]. Biochern Biophys commun,1984,118(1):103-109
[20]Mishra J, Mori K, Ma Q, et al. Amelioration of ischemic acute renal injury by neutrohpil gelatinize-associated lipocalin[J]. J Am Soc Nephrol,2004,15(12): 3073
[21]Le Bricon T, Thervet E, Froissart M, et al. Plasma cystain C is superior to 24h creatinine clearrance.and plasma creatinine for estimation of glomerular filtration rate 3 months after kidney transplantation [J]. Clin Chem,2000,46(8):1206-1207
[22]李希华,秦尔斌.肾损伤的诊断与治疗[J].国际泌尿系统杂志,1982年05期
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[44]]李楠.原发性肾病综合征并发急性肾功能衰竭临床分析.中国实用医药,2012,7(2)；132-133.
[45]周武威；黄坚毅.周武威.原发性肾病综合征并发急性肾功能衰竭18例临床分析.医学信息：中旬刊,2011,24(8)；3977-3978.
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25. Melcalfe W, simpson M, Khan Ⅱ-Ⅰ, et al. Acute renal falime requiringrenal replaeemont:incidence and outeome[J].2002,95(19):579-583.
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[19]Brzin J, Popovic T, Turk V. Human cystatin, a new protein inhibitor of cysteine proteinases [J]. Biochern Biophys commun,1984,118(1):103-109
[20]Mishra J, Mori K, Ma Q, et al. Amelioration of ischemic acute renal injury by neutrohpil gelatinize-associated lipocalin[J]. J Am Soc Nephrol,2004,15(12): 3073
[21]Le Bricon T, Thervet E, Froissart M, et al. Plasma cystain C is superior to 24h creatinine clearrance.and plasma creatinine for estimation of glomerular filtration rate 3 months after kidney transplantation [J]. Clin Chem,2000,46(8):1206-1207
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[24]王川.慢性缺血性肾损伤及损伤机制的临床与实验研究[D]；第四军医大学；2002年
[25]Melcalfe W, simpson M, Khan Ⅱ-Ⅰ, d al, Acute renal falime requiringrenal replaeemont: incidence and outeome[J].2002,95(19):579-583.
[26]张榕.系统性红斑狼疮患者血清IL-15检测及其对肾损伤的评价[D]；中国医科大学；2002年
[27]左力,千梅,王海燕.急性肾功能衰竭误漏诊原因分析及肾活检的意义[J].中华内科杂志,1999,38(8)：537-540.
[28]王海燕.急性肾损伤临床研究的思考与建议[J].中华肾病杂志,2006,22(11)：649-651.
[29]急性肾损伤专家共识小组.急性肾损伤诊断与分类专家共识.中华肾脏病杂志,2006,22(11)：661-663.
[30]贝政平.2000个国内外最新实用内科诊断标准.上海：上海同济大学出版社,1991：213.
[31]黎磊石.重视庆大霉素的肾毒性问题[J]..中华内科杂志,1986,25(4)：193.
[32]王海燕.肾脏病学,第2版.北京：人民卫生出版社,1996,1370.
[33]陶岳多.庆大霉素的毒副作用及其防治[J]..实用内科杂志,1985,5(12)：708-709.
[34]汪关煜,董得长.我国急性肾衰的现状.中华内科杂志,1994,33(8)：566.
[35]Appel GB, Neu HC. The nephrotoxiety of antimicrobial agents (second of three parts) [J]. N Engl J Med,1977,296 (13):772-728.
[36]李晓玫.慢性肾脏病基础上急性肾衰竭的诊断与防治[J].中华肾脏病杂志,2006年11期
[37]齐虹,李晓芳,庞旭静,等.药物引起的急性肾功能衰竭统计与分析[J].中国现代药物应用,2012,6(23)；58-59
[38]朴成林.210例老年肾功能衰竭血液透析观察分析[J].中国实用医药,2008,3(2)；86-86
[39]周志明.老年慢性肾脏病40例的病因分析及诊治体会[J].中国民族民间医药杂志,2010,19(16)；194-194.
[40]杨新军,张训,侯凡凡.老年人急性肾功能衰竭的临床特点[J].中华老年医学杂志,2002,21(4)：251-253.
[41]张文,陈楠,任红,等.急性肾功能衰竭流行病学调查[J].肾脏病与透析肾移植杂志,2002,11：323-327.
[42]陈泽琼.原发性肾病综合征并发急性肾功能衰竭13例临床分析.华北煤炭医学院学报,2009,11(1)；71-72.
[43]黎君君,梁正林.黎君君.原发性肾病综合征并发急性肾功能衰竭29例临床与病理分析.内科,2009,4(5)；732-733.
[44]]李楠.原发性肾病综合征并发急性肾功能衰竭临床分析.中国实用医药,2012,7(2)；132-133.
[45]周武威；黄坚毅.周武威.原发性肾病综合征并发急性肾功能衰竭18例临床分析.医学信息：中旬刊,2011,24(8)；3977-3978.
[46]韩亮.原发性肾病综合征并急性肾功能衰竭临床分析.中国实用医药,2011,6(30)；104-105
[47]周萍,孙敏燕,孙章松,等.周萍,孙敏燕.原发性肾病综合征并发急性肾功能衰竭45例分析.中国现代医生,2011,49(29)；49-50.
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[49]吉程程.急性肾损伤定义、诊断及防治进展[J].中国血液净化，2008,7：46-48.
[50]季大玺.急性肾损伤与连续性血液净化[J].中国血液净化,2006,5(12)：819-821.
[51]李家瑞.不同血液净化方法对脓毒症性急性肾损伤的预后影响[J].中华急诊医学杂志,2009,18(2)：136-139.
[52]Altintepe L, Guney I, Tonbul Z, et al. Early and intensive fluid replacement prevents acute renal failure in the crush cases associated with spontaneous collapse of an apartment in Konya[J]. Ren Fail,2007,29:737-741.
[53]Kopp JB, Ball LK, Cohen A, et al. Kidney patient care in disasters:lessons from the hurricanes and earthquake of 2005[J]. Clin J Am Soc Nephrol,2007,2: 814-824.
[54]Sever MS, Erek E, Vanholder R, et al. Clinical findings in the renal victims of a catastrophic disaster:the Marmara earthquake[J]. Nephrol Dial Transplant, 2002,17:1942-1949.
[55]黎磊石季大玺.连续性血液净化[M].南京：东南大学出版社,2004.159-163.