入院时急性肾损伤对重症肺炎并发脓毒症患者预后的预测价值
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摘要
目的明确入院时急性肾损伤(acute kidney injury,AKI)对重症肺炎并发脓毒症患者预后的预测价值。方法回顾性分析2015年7月—2016年6月四川大学华西医院急诊科462例重症肺炎并发脓毒症患者的人口学资料、生命体征、实验室检查等资料,及7 d和28 d病死率、28 d机械通气率、28 d重症监护室(intensive care unit,ICU)住院率。采用多因素logistic回归分析入院时AKI和重症肺炎并发脓毒症患者28 d死亡的相关性。结果入院时AKI患者比非AKI患者具有更高比例的7 d(24.6%vs. 9.7%,P=0.001)和28 d病死率(44.3%vs.21.2%,P<0.001)、28 d机械通气率(63.9%vs. 45.9%,P=0.009)和28 d ICU住院率(65.6%vs. 39.4%,P<0.001)。入院时AKI患者全身性感染相关性功能衰竭评分(SOFA)和急性生理功能和慢性健康状况评分系统Ⅱ(APACHEⅡ)得分明显高于入院时非AKI患者,差异均有统计学意义(P<0.05)。多因素logistic回归分析显示,入院时AKI是重症肺炎并发脓毒症患者28 d死亡的独立危险因素[优势比为2.266,95%置信区间(1.058,4.854),P=0.035)]。结论入院时发生AKI可用于预测重症肺炎并发脓毒症患者不良预后,有助于指导早期精准干预。
Objective To investigate the prognostic value of acute kidney injury(AKI) in patients with severe pneumonia complicated with sepsis. Methods We retrospectively analyzed the demographic data, vital signs, laboratory examination and other data of 462 patients with severe pneumonia complicated with sepsis in the Department of Emergency West China hospital, Sichuan University from July 2015 to June 2016, as well as the 7-day and 28-day mortality, 28-day mechanical ventilation rate and 28-day intensive care unit(ICU) hospitalization rate. Multivariate logistic regression analysis was used to determine the correlation between AKI and 28-day mortality in patients with severe pneumonia complicated with sepsis at admission. Results A total of 462 patients with severe pneumonia complicated with sepsis were retrospectively enrolled in this study. AKI patients at admission had a higher proportion of7-day(24.6% vs. 9.7%, P<0.001) and 28-day mortality(44.3% vs. 21.2%, P<0.001), 28-day mechanical ventilation rate(63.9% vs. 45.9%, P=0.009) and 28-day ICU admission rate(65.6% vs. 39.4%, P<0.001) than non-AKI patients. There was a significant difference between the two groups(P<0.05). The scores of systemic infection-related organ failure assessment and acute physiology and chronic health evaluationⅡof AKI patients at admission were significantly higher than those of non-AKI patients at admission(P<0.05). Multivariate logistic regression analysis showed that AKI at admission was an independent risk factor for 28-day mortality in patients with severe pneumonia complicated with sepsis [odds ratio: 2.266,95% confidence interval(1.058, 4.854), P=0.035]. Conclusion AKI at admission is helpful for identifying high-risk pneumonia patients complicated with sepsis, and thus may guide the clinical managements of precise medicine.
Objective To investigate the prognostic value of acute kidney injury(AKI) in patients with severe pneumonia complicated with sepsis. Methods We retrospectively analyzed the demographic data, vital signs, laboratory examination and other data of 462 patients with severe pneumonia complicated with sepsis in the Department of Emergency West China hospital, Sichuan University from July 2015 to June 2016, as well as the 7-day and 28-day mortality, 28-day mechanical ventilation rate and 28-day intensive care unit(ICU) hospitalization rate. Multivariate logistic regression analysis was used to determine the correlation between AKI and 28-day mortality in patients with severe pneumonia complicated with sepsis at admission. Results A total of 462 patients with severe pneumonia complicated with sepsis were retrospectively enrolled in this study. AKI patients at admission had a higher proportion of7-day(24.6% vs. 9.7%, P<0.001) and 28-day mortality(44.3% vs. 21.2%, P<0.001), 28-day mechanical ventilation rate(63.9% vs. 45.9%, P=0.009) and 28-day ICU admission rate(65.6% vs. 39.4%, P<0.001) than non-AKI patients. There was a significant difference between the two groups(P<0.05). The scores of systemic infection-related organ failure assessment and acute physiology and chronic health evaluationⅡof AKI patients at admission were significantly higher than those of non-AKI patients at admission(P<0.05). Multivariate logistic regression analysis showed that AKI at admission was an independent risk factor for 28-day mortality in patients with severe pneumonia complicated with sepsis [odds ratio: 2.266,95% confidence interval(1.058, 4.854), P=0.035]. Conclusion AKI at admission is helpful for identifying high-risk pneumonia patients complicated with sepsis, and thus may guide the clinical managements of precise medicine.
引文
1Montull B, Menéndez R, Torres A, et al. Predictors of severe sepsis among patients hospitalized for community-acquired pneumonia.PLoS One, 2016, 11(1):e0145929.
2 中国医师协会急诊医师分会.中国急诊重症肺炎临床实践专家共识.中国急救医学, 2016, 36(2):97-107.
3Verdonk F, Blet A, Mebazaa A. The new sepsis definition:limitations and contribution to research and diagnosis of sepsis.Curr Opin Anaesthesiol, 2017, 30(2):200-204.
4 曹钰,柴艳芬,邓颖,等.中国脓毒症/脓毒性休克急诊治疗指南(2018).临床急诊杂志, 2018, 19(9):567-588.
5Godinjak A, Iglica A, Rama A, et al. Predictive value of SAPSⅡand APACHEⅡscoring systems for patient outcome in a medical intensive care unit. Acta Med Acad, 2016, 45(2):97-103.
6 Innocenti F, Tozzi C, Donnini C, et al. SOFA score in septic patients:incremental prognostic value over age, comorbidities, and parameters of sepsis severity. Intern Emerg Med, 2018, 13(3):405-412.
7侯彦广,刘修恒,王磊,等.表观遗传学在肾缺血/再灌注损伤中的研究进展.医学综述, 2018, 24(18):3570-3574.
8 Chawla LS, Bellomo R, Bihorac A, et al. Acute kidney disease and renal recovery:consensus report of the Acute Disease Quality Initiative(ADQI)16 workgroup. Nat Rev Nephrol, 2017, 13(4):241-257.
9Závada J, Hoste E, Cartin-Ceba R, et al. A comparison of three methods to estimate baseline creatinine for RIFLE classification.Nephrol Dial Transplant, 2010, 25(12):3911-3918.
10 Du J, Abdel-Razek O, Shi Q, et al. Surfactant protein D attenuates acute lung and kidney injuries in pneumonia-induced sepsis through modulating apoptosis, inflammation and NF-κB signaling.Sci Rep, 2018, 8(1):15393.
11Akram AR, Singanayagam A, Choudhury G, et al. Incidence and prognostic implications of acute kidney injury on admission in patients with community-acquired pneumonia. Chest, 2010,138(4):825-832.
12 Murugan R, Karajala-Subramanyam V, Lee M, et al. Acute kidney injury in non-severe pneumonia is associated with an increased immune response and lower survival. Kidney Int, 2010, 77(6):527-535.
13Darmon M, Clec'h C, Adrie C, et al. Acute respiratory distress syndrome and risk of AKI among critically ill patients. Clin J Am Soc Nephrol, 2014, 9(8):1347-1353.
14 Uchino S, Kellum JA, Bellomo R, et al. Acute renal failure in critically ill patients:a multinational, multicenter study. JAMA,2005, 294(7):813-818.
15Bagshaw SM, George C, Bellomo R, et al. Early acute kidney injury and sepsis:a multicentre evaluation. Crit Care, 2008, 12(2):R47.
16 White LE, Hassoun HT, Bihorac A, et al. Acute kidney injury is surprisingly common and a powerful predictor of mortality in surgical sepsis. J Trauma Acute Care Surg, 2013, 75(3):432-438.
17Godin M, Murray P, Mehta RL. Clinical approach to the patient with AKI and sepsis. Semin Nephrol, 2015, 35(1):12-22.
2 中国医师协会急诊医师分会.中国急诊重症肺炎临床实践专家共识.中国急救医学, 2016, 36(2):97-107.
3Verdonk F, Blet A, Mebazaa A. The new sepsis definition:limitations and contribution to research and diagnosis of sepsis.Curr Opin Anaesthesiol, 2017, 30(2):200-204.
4 曹钰,柴艳芬,邓颖,等.中国脓毒症/脓毒性休克急诊治疗指南(2018).临床急诊杂志, 2018, 19(9):567-588.
5Godinjak A, Iglica A, Rama A, et al. Predictive value of SAPSⅡand APACHEⅡscoring systems for patient outcome in a medical intensive care unit. Acta Med Acad, 2016, 45(2):97-103.
6 Innocenti F, Tozzi C, Donnini C, et al. SOFA score in septic patients:incremental prognostic value over age, comorbidities, and parameters of sepsis severity. Intern Emerg Med, 2018, 13(3):405-412.
7侯彦广,刘修恒,王磊,等.表观遗传学在肾缺血/再灌注损伤中的研究进展.医学综述, 2018, 24(18):3570-3574.
8 Chawla LS, Bellomo R, Bihorac A, et al. Acute kidney disease and renal recovery:consensus report of the Acute Disease Quality Initiative(ADQI)16 workgroup. Nat Rev Nephrol, 2017, 13(4):241-257.
9Závada J, Hoste E, Cartin-Ceba R, et al. A comparison of three methods to estimate baseline creatinine for RIFLE classification.Nephrol Dial Transplant, 2010, 25(12):3911-3918.
10 Du J, Abdel-Razek O, Shi Q, et al. Surfactant protein D attenuates acute lung and kidney injuries in pneumonia-induced sepsis through modulating apoptosis, inflammation and NF-κB signaling.Sci Rep, 2018, 8(1):15393.
11Akram AR, Singanayagam A, Choudhury G, et al. Incidence and prognostic implications of acute kidney injury on admission in patients with community-acquired pneumonia. Chest, 2010,138(4):825-832.
12 Murugan R, Karajala-Subramanyam V, Lee M, et al. Acute kidney injury in non-severe pneumonia is associated with an increased immune response and lower survival. Kidney Int, 2010, 77(6):527-535.
13Darmon M, Clec'h C, Adrie C, et al. Acute respiratory distress syndrome and risk of AKI among critically ill patients. Clin J Am Soc Nephrol, 2014, 9(8):1347-1353.
14 Uchino S, Kellum JA, Bellomo R, et al. Acute renal failure in critically ill patients:a multinational, multicenter study. JAMA,2005, 294(7):813-818.
15Bagshaw SM, George C, Bellomo R, et al. Early acute kidney injury and sepsis:a multicentre evaluation. Crit Care, 2008, 12(2):R47.
16 White LE, Hassoun HT, Bihorac A, et al. Acute kidney injury is surprisingly common and a powerful predictor of mortality in surgical sepsis. J Trauma Acute Care Surg, 2013, 75(3):432-438.
17Godin M, Murray P, Mehta RL. Clinical approach to the patient with AKI and sepsis. Semin Nephrol, 2015, 35(1):12-22.