切换至 "中华医学电子期刊资源库"

第五届中国出版政府奖音像电子网络出版物奖提名奖

中国科技核心期刊

中国科学引文数据库(CSCD)来源期刊

中华重症医学电子杂志 ›› 2021, Vol. 07 ›› Issue (02): 103 -109. doi: 10.3877/cma.j.issn.2096-1537.2021.02.002

临床研究 上一篇    下一篇

凝血SOFA评分对严重脓毒症相关急性肾损伤患者预后的预测价值
冀晓俊 1 , ( ), 林瑾 1, 王海曼 1, 段美丽 1   
  1. 1. 100050 首都医科大学附属北京友谊医院重症医学科
  • 收稿日期:2021-03-19 出版日期:2021-05-28
  • 通信作者: 冀晓俊

Value of baseline SOFA coagulation score for prediction of prognosis in patients with severe sptic AKI

Xiaojun Ji 1( ), Jin Lin 1, Haiman Wang 1, Meili Duan 1   

  1. 1. Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
  • Received:2021-03-19 Published:2021-05-28
  • Corresponding author: Xiaojun Ji
目的

评估基础凝血序贯器官衰竭评估(SOFA)评分对需要持续性肾替代治疗(CRRT)的严重脓毒症相关急性肾损伤(S-AKI)患者预后的预测价值。

方法

回顾性分析2017年1月至2020年10月首都医科大学附属北京友谊医院ICU收治的180例诊断为S-AKI且接受CRRT患者的临床资料,根据基础凝血SOFA评分分为凝血SOFA评分正常组(凝血SOFA评分=0)和凝血SOFA评分异常组(凝血SOFA评分≥1),主要结局指标为CRRT启动后60 d全因病死率。采用多因素Cox回归模型分析基础凝血SOFA评分及其他因素对临床预后的影响。

结果

本研究共纳入180例患者,凝血SOFA评分正常组66例,凝血SOFA评分异常组114例。凝血SOFA评分正常组60 d病死率为45.5%(30/66),凝血SOFA评分异常组60 d病死率为64.0%(73/114),2组间病死率比较差异有统计学意义(P=0.015)。2组间ICU住院时间(P=0.870)及肾替代时长(P=0.270)比较差异无统计学意义(P>0.05)。多因素Cox回归分析显示,在校正了其他因素的影响后,凝血SOFA评分异常是接受CRRT的S-AKI患者60 d死亡的独立危险因素(HR=1.616,P=0.034)。

结论

异常的凝血SOFA评分在需要CRRT的S-AKI患者中是常见的现象,开始CRRT前异常的凝血SOFA评分与60 d病死率增加显著相关。

Objective

To evaluate the prognostic value of baseline SOFA coagulation score (SOFA-CS) in patients with septic acute kidney injury (S-AKI) requiring continuous renal replacement therapy (CRRT).

Methods

This retrospective study included 180 patients with S-AKI receiving CRRT from January 2017 to October 2020 in the Department of Critical Care Medicine of Beijing Friendship Hospital affiliated to Capital Medical University. Patients were divided into normal SOFA-CS group (SOFA-CS=0) and abnormal SOFA-CS group (SOFA-CS≥1). The primary outcome was all-cause mortality at 60 days after initiation of CRRT. The association between baseline SOFA-CS, process of care, and clinical outcomes were analysed using multivariate Cox model adjusted for baseline variables.

Results

Among 180 S-AKI patients, 66 patients had normal SOFA-CS at baseline, while 114 patients had an abnormal SOFA-CS. The 60-day mortality rate in abnormal SOFA-CS group was higher than that in normal SOFA-CS group (45.5% vs 64.0%, P=0.015). There was no significant difference in the length of ICU stay (P=0.870) and duration of CRRT (P=0.270) between two groups. Multivariable Cox regression analysis showed that an abnormal SOFA-CS was independently associated with an increased risk of death at 60 days (HR=1.616, P=0.034).

Conclusion

Abnormal coagulation is a common phenomenon in patients with S-AKI receiving CRRT. An abnormal baseline SOFA coagulation score is associated with increased mortality at 60 days.

表1 凝血SOFA评分正常组和凝血SOFA评分异常组一般资料比较
一般资料 总体 凝血SOFA评分正常组(66例) 凝血SOFA评分异常组(114例) 统计值 P
年龄(岁,
x ¯
±s
63.0±17.3 67.2±16.6 60.5±17.4 t=2.527 0.012
男性[例(%)] 122(67.8) 46(69.7) 76(66.7) χ2=0.176 0.740
糖尿病[例(%)] 47(26.1) 25(37.9) 22(19.3) χ2=7.480 0.008
慢性肝病[例(%)] 16(8.9) 1(1.5) 15(13.2) χ2=6.996 0.006
慢性肾病[例(%)] 36(20.0) 17(25.8) 19(16.7) χ2=2.159 0.180
APACHEⅡ评分(分,
x ¯
±s
24.9±7.5 25.5±7.0 24.5±7.8 t=0.821 0.410
SOFA评分(分,
x ¯
±s
10.4±3.9 8.5±3.4 11.5±3.8 t=5.339 <0.001
呼吸机应用[例(%)] 102(56.7) 34(51.5) 68(59.6) χ2=1.126 0.350
脓毒性休克[例(%)] 136(75.6) 45(68.2) 91(79.8) χ2=3.068 0.110
血Lac[mmol/L,MQ25Q75)] 2.4(1.4,5.2) 1.9(1.1,4.3) 2.6(1.6,5.4) Z=0.337 0.070
WBC(×109/L,
x ¯
±s
12.7±7.8 14.3±7.9 11.8±7.6 t=2.122 0.035
Hb(g/L,
x ¯
±s
94.5±27.2 97.4±29.0 92.7±26.1 t=1.117 0.270
Plt(×109/L,
x ¯
±s
123.4±92.7 215.7±85.7 69.8±38.9 t=15.632 <0.001
SCr[μmol/L,MQ25Q75)] 246(155,411) 249(160,407) 244(151,420) Z=0.193 0.850
BUN(mmol/L,
x ¯
±s
22.0±13.8 20.6±11.9 22.8±14.8 t=1.037 0.300
Alb(g/L,
x ¯
±s
25.8±5.4 25.7±5.1 25.8±5.5 t=0.125 0.900
血钾(mmol/L,
x ¯
±s
4.5±0.8 4.6±1.0 4.5±0.7 t=0.386 0.700
血糖(mmol/L,
x ¯
±s
10.5±5.4 11.7±5.7 9.7±5.1 t=2.445 0.015
氧合指数(mmHg,
x ¯
±s
212.1±121.7 189.4±116.9 225.6±123.2 t=1.627 0.110
碳酸氢根(mmol/L,
x ¯
±s
21.1±5.7 21.2±5.5 21.1±5.8 t=0.245 0.810
PT[s,MQ25Q75)] 18(14,23) 14(13,20) 18(14,23) Z=1.332 0.180
感染部位[例(%)] χ2=0.357 0.980
肺部 105(58.3) 38(57.6) 67(58.8)
腹腔 53(29.4) 20(30.3) 33(28.9)
尿道 7(3.9) 3(4.5) 4(3.5)
血液 8(4.4) 3(4.5) 5(4.4)
其他 7(3.9) 2(3.0) 5(4.4)
表2 凝血SOFA评分正常组和凝血SOFA评分异常组预后比较
图1 凝血SOFA评分正常组和凝血SOFA评分异常组60 d Kaplan-Meier生存曲线
表3 严重S-AKI患者接受CRRT后60 d时存活组及死亡组一般资料比较
一般资料 总体 存活组(77例) 死亡组(103例) 统计值 P
年龄(岁,
x ¯
±s
63.0±17.3 59.6±15.9 65.5±18.1 t=2.297 0.023
男性[例(%)] 122(67.8) 57(74.0) 65(63.1) χ2=2.405 0.150
糖尿病[例(%)] 47(26.1) 22(28.6) 25(24.3) χ2=0.422 0.610
慢性肝病[例(%)] 16(8.9) 4(5.2) 12(11.7) χ2=2.267 0.190
慢性肾病[例(%)] 36(20.0) 21(27.3) 15(14.6) χ2=4.448 0.040
APACHEⅡ评分(分,
x ¯
±s
24.9±7.5 22.9±6.1 26.3±8.1 t=2.996 0.003
SOFA评分(分,
x ¯
±s
10.4±3.9 9.0±3.6 11.4±3.8 t=4.405 <0.001
呼吸机应用[例(%)] 102(56.7) 36(46.8) 66(64.1) χ2=5.385 0.023
脓毒性休克[例(%)] 136(75.6) 46(59.7) 90(87.4) χ2=18.224 <0.001
血Lac[mmol/L,MQ25Q75)] 2.4(1.4,5.2) 1.8(1.1,4.1) 2.7(1.7,5.8) Z=2.268 0.003
WBC(×109/L,
x ¯
±s
12.7±7.8 12.5±7.3 12.8±8.2 t=0.284 0.780
Hb(g/L,
x ¯
±s
94.5±27.2 100.0±29.4 90.4±24.8 t=2.373 0.019
Plt(×109/L,
x ¯
±s
123.4±92.7 150.8±102.2 102.7±78.4 t=3.556 <0.001
CRRT开始后3 d Plt下降[例(%)] 83(46.1) 32(41.5) 51(49.5) χ2=1.122 0.289
SCr[μmol/L,MQ25Q75)] 246(155,411) 264(176,446) 233(145,394) Z=1.681 0.090
BUN(mmol/L,
x ¯
±s
22.0±13.8 23.0±14.7 20.8±12.6 t=1.025 0.310
Alb(g/L,
x ¯
±s
25.8±5.4 26.7±4.8 25.1±5.7 t=2.032 0.044
血钾(mmol/L,
x ¯
±s
4.5±0.8 4.4±0.8 4.6±0.8 t=1.894 0.060
血糖(mmol/L,
x ¯
±s
10.5±5.4 10.0±4.2 10.8±6.1 t=0.984 0.330
氧合指数(mmHg,
x ¯
±s
212.1±121.7 225.1±100.1 204.9±132.2 t=0.892 0.370
碳酸氢根(mmol/L,
x ¯
±s
21.1±5.7 20.8±5.7 21.4±5.7 t=0.643 0.520
PT[s,MQ25Q75)] 18(14,23) 16(13,20) 18(16,25) Z=1.162 0.240
感染部位[例(%)] χ2=7.963 0.093
肺部 105(58.3) 38(49.4) 67(65)
腹腔 53(29.4) 29(37.7) 24(23.3)
尿道 7(3.9) 5(6.5) 2(1.9)
血液 8(4.4) 3(3.9) 5(4.9)
其他 7(3.9) 2(2.6) 5(4.9)
表4 严重S-AKI患者接受CRRT后60 d死亡的Cox回归分析单因素模型
表5 严重S-AKI患者接受CRRT后60 d死亡的Cox回归分析多因素模型
1
Cruz DN, Ronco C. Acute kidney injury in the intensive care unit: current trends in incidence and outcome [J]. Crit Care, 2007, 11(4): 149.
2
Uchino S, Kellum JA, Bellomo R, et al. Beginning and ending supportive therapy for the kidney (BEST Kidney) investigators: acute renal failure in critically ill patients: a multinational, multicenter study [J]. JAMA, 2005, 294: 813-818.
3
Bagshaw SM, Uchino S, Bellmo 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.
4
Uchino S, Bellomo R, Goldsmith D, et al. An assessment of the RIFLE criteria for acute renal failure in hospitalized patients [J]. Crit Care Med, 2006, 34(7): 1913-1917.
5
Metnitz PG, Krenn CG, Steltzer H, et al. Effect of acute renal failure requiring renal replacement therapy on outcome in critically ill patients [J]. Crit Care Med, 2002, 30(9): 2051-2058.
6
Guru PK, Singh TD, Akhoundi A, et al. Association of thrombocytopenia and mortality in critically ill patients on continuous renal replacement therapy [J]. Nephron, 2016, 133(3): 175-182.
7
Chertow GM, Soroko SH, Paganini EP, et al. Mortality after acute renal failure: models for prognostic stratification and risk adjustment [J]. Kidney Int, 2006, 70(6): 1120-1126.
8
Levi M. Platelets in critical illness[J]. Semin Thromb Hemost, 2016, 42(3): 252-257.
9
Wu B, Gong D, Xu B, et al. Decreased platelet count in patients receiving continuous veno-venous hemofiltration: a single-center retrospective study [J]. PLoS One, 2014, 9(5): e97286.
10
Rhodes A, Evans LE, Alhazzani W, et al. Surviving sepsis campaign: international guidelines for management of sepsis and septic shock: 2016 [J]. Intensive Care Med, 2017 43(3): 304-377.
11
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.
12
杨向红, 张丽娜, 胡波, 等. 连续性肾替代治疗规范化治疗流程 [J/OL]. 中华重症医学电子杂志, 2019, 5(1): 27-31.
13
Lin J, Gallagher M, Bellomo R, et al. SOFA coagulation score and changes in platelet counts in severe acute kidney injury: Analysis from the randomized evaluation of normal versus augmented level (RENAL) study [J]. Nephrology (Carlton), 2019, 24(5): 518-525.
14
Di Dedda U, Ranucci M, Porta A, et al. The combined effects of the microcirculatory status and cardiopulmonary bypass on platelet count and function during cardiac surgery [J]. Clin Hemorheol Microcirc 2018, 70: 327-337.
15
Katz JN, Kolappa KP, Becker RC. Beyond thrombosis: The versatile platelet in critical illness [J]. Chest, 2011, 139: 658-668.
16
Bozza FA, Shah AM, Weyrich AS, et al. Amicus or adversary: Platelets in lung biology, acute injury, and inflammation [J]. Am J Respir Cell Mol Biol 2009, 40: 123-134.
17
Griffin BR, Jovanovich A, You Z, et al. Effects of baseline thrombocytopenia and platelet decrease following RRT initiation in patients with severe AKI [J]. Crit Care Med, 2019, 47(4): e325-e331.
18
宋雨薇,柴艳芬. 脓毒症合并急性肾损伤患者继发血小板减少症的危险因素分析 [J].中华临床感染病杂志, 2017, 10(3): 391-394.
19
Strauss R, Wehler M, Mehler K, et al. Thrombocytopenia in patients in the medical intensive care unit: bleeding prevalence, transfusion requirements, and outcome [J]. Crit Care Med, 2002, 30(8): 1765-1771.
20
Mulder J, Tan HK, Bellomo R, et al. Platelet loss across the hemofilter during continuous hemofiltration [J]. Int J Artif Organs, 2003, 26(10): 906-912.
21
Detlef KM, Timo B, Thomas D. Regional citrate anticoagulation for continuous renal replacement therapy [J]. Curr Opin Crit Care, 2018, 24(6): 450-454.
22
Hetzel GR, Schmitz M, Wissing H, et al. Regional citrate versus systemic heparin for anticoagulation in critically ill patients on continuous venovenous haemofiltration: a prospective randomized multicentre trial [J]. Nephrol Dial Transplant, 2011, 26(1): 232-239.
23
Moreau D, Timsit JF, Vesin A, et al. Platelet count decline: an early prognostic marker in critically ill patients with prolonged ICU stays [J]. Chest, 2007, 131(6): 1735-1741.
24
王逸平, 姜岱山, 刘向新, 等. 血小板减少与接受连续性肾脏替代治疗急性肾损伤患者短期预后的相关性 [J]. 中国急救医学, 2020, 40(2): 108-112.
25
Valente C, Soares M, Rocha E, et al. The evaluation of sequential platelet counts has prognostic value for acute kidney injury patients requiring dialysis in the intensive care setting [J]. Clinics, 2013, 68(6): 803-808.
[1] 赵萍, 王烁, 李秋洋, 王一茹, 朱连华, 宋青, 罗渝昆, 唐杰. 超声造影评价横纹肌溶解致急性肾损伤肾的血流灌注实验[J]. 中华医学超声杂志(电子版), 2022, 19(03): 248-255.
[2] 王烁, 赵萍, 李秋洋, 张颖, 宋青, 朱嘉宁, 朱连华, 罗渝昆. 超声造影定量评价脓毒症急性肾损伤肾血流灌注及其参数与炎症因子的相关性[J]. 中华医学超声杂志(电子版), 2022, 19(01): 59-65.
[3] 樊恒, 乐健伟, 叶继辉, 孙敏, 朱建华. N-乙酰半胱氨酸对脓毒症小鼠急性肾损伤的保护作用及机制研究[J]. 中华危重症医学杂志(电子版), 2021, 14(03): 180-186.
[4] 陈华萍, 甘志新, 刘刚, 刘双林, 刘禹, 焦玉丁, 缪殿南, 徐静, 王关嵩, 徐智, 李琦, 胡明冬. 慢性阻塞性肺疾病的合并症/并发症的发病率和病死率分析[J]. 中华肺部疾病杂志(电子版), 2021, 14(04): 417-421.
[5] 陈钰澜, 陈健文, 朱飞, 王田田, 张妍, 刘娇娜, 黄梦杰, 吴玲玲, 陈香美. 紫草素抑制缺血再灌注肾损伤后肾小管细胞的增殖和迁移[J]. 中华肾病研究电子杂志, 2022, 11(01): 15-21.
[6] 王东, 张亚伟, 丁小桐, 倪洁. 激活素A在肾脏疾病中的作用研究进展[J]. 中华肾病研究电子杂志, 2022, 11(01): 48-51.
[7] 苏涛. 免疫检查点抑制剂相关肾脏损伤[J]. 中华肾病研究电子杂志, 2021, 10(06): 301-305.
[8] 廖智菲, 焦元野, 樊佩琦, 武玲宇, 郭罡玲, 李静, 王利华. 2016~2019年山西省血液透析死亡患者流行病学调查[J]. 中华肾病研究电子杂志, 2021, 10(05): 241-245.
[9] 李美媛, 刘康, 邬步云, 俞香宝, 朱亚梅, 毛慧娟, 邢昌赢. 冠状动脉造影术到心脏瓣膜手术时间间隔对术后急性肾损伤发生的影响[J]. 中华肾病研究电子杂志, 2021, 10(03): 126-132.
[10] 贾丽芳, 周培一, 白文英. 慢性肾脏病患者经皮冠脉介入术后急性肾损伤预后及影响因素分析[J]. 中华肾病研究电子杂志, 2021, 10(03): 133-137.
[11] 罗晴, 彭婷, 张伟光, 程晓巍, 王滨, 陈意志. 新冠病毒感染患者并发急性肾损伤与临床预后相关性的Meta分析[J]. 中华肾病研究电子杂志, 2021, 10(03): 138-143.
[12] 周旺涛, 于湘友, 居来提·肉扎洪, 郭驹, 李颖, 宋云林. 急性Stanford A型主动脉夹层患者术后短期病死率的影响因素[J]. 中华重症医学电子杂志, 2022, 08(01): 31-36.
[13] 李军, 高科, 王静妮, 柳建. 2015年至2020年六盘水市孕产妇死亡评审调查分析[J]. 中华重症医学电子杂志, 2021, 07(04): 315-318.
[14] 姚哲放, 王美霞, 赵兰, 王彩虹, 王亚丽. 老年重症患者蛋白质供给量与预后的相关性[J]. 中华临床医师杂志(电子版), 2021, 15(05): 347-352.
[15] 刘景卓, 马莉. 艾司洛尔对脓毒症急性肾损伤大鼠的保护作用[J]. 中华临床医师杂志(电子版), 2021, 15(04): 280-287.
阅读次数
全文


摘要