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中华重症医学电子杂志 doi: 10.3877/cma.j.issn.2096-1537.2025.03.22-0006

临床研究

接受肾脏替代治疗的脓毒症相关急性肾损伤危重患者早期死亡的危险因素及其预测价值
林瑾1,(), 赵宸龙1, 岳之琳1, 段美丽1   
  1. 1. 100050 北京,首都医科大学附属北京友谊医院重症医学科
  • 收稿日期:2024-08-26
  • 通信作者: 林瑾
  • 基金资助:
    首都卫生发展专项项目(首发2024-2-1179)

Risk factors and predictive value of early mortality in critically ill patients with septic acute kidney injury requiring renal replacement therapy

Jin Lin1,(), Chenlong Zhao1, Zhilin Yue1, Meili Duan1   

  1. 1. Department of Critical Care Medicine, Beijing Friendship Hospital, Capital Medical University, Beijing 100050, China
  • Received:2024-08-26
  • Corresponding author: Jin Lin
引用本文:

林瑾, 赵宸龙, 岳之琳, 段美丽. 接受肾脏替代治疗的脓毒症相关急性肾损伤危重患者早期死亡的危险因素及其预测价值[J/OL]. 中华重症医学电子杂志, doi: 10.3877/cma.j.issn.2096-1537.2025.03.22-0006.

Jin Lin, Chenlong Zhao, Zhilin Yue, Meili Duan. Risk factors and predictive value of early mortality in critically ill patients with septic acute kidney injury requiring renal replacement therapy[J/OL]. Chinese Journal of Critical Care & Intensive Care Medicine(Electronic Edition), doi: 10.3877/cma.j.issn.2096-1537.2025.03.22-0006.

目的

探讨影响脓毒症相关急性肾损伤(SAKI)患者启动连续性肾脏替代治疗(CRRT)后48 内死亡的相关危险因素,同时评价这些危险因素对患者早期死亡的预测价值。

方法

对首都医科大学附属北京友谊医院重症医学科2016年1月至2021年12月收治的SAKI接受CRRT的258例患者的临床资料进行回顾性分析,根据患者是否在48 h内死亡分为存活组(203例)和死亡组(55例),以患者CRRT启动后48 h是否死亡为二分类结局变量,采用logistic回归评估早期死亡的影响因素,针对独立危险因素应用logistic回归构建联合预测因子,绘制受试者工作特征曲线(ROC)分析该联合预测因子对早期死亡的预测价值。

结果

258例接受CRRT的SAKI患者的早期病死率为21.3%。多因素二元logistic回归分析结果显示低肌酐水平[OR=1.50(每降低100 μmol/L),95%CI:1.15~1.95],低氧合指数[OR=1.05(每降低10 mmHg),95%CI:1.02~1.09]及乳酸升高[OR=1.20(每升高1 mmol/L),95%CI:1.10~1.30]是接受CRRT治疗的SAKI患者早期死亡的独立危险因素。通过logistic回归生成新的联合预测因子,使用新的联合因子绘制ROC曲线,结果显示联合预测因子预测早期死亡的曲线下面积(AUC)为0.804。

结论

在接受CRRT的SAKI危重患者中低肌酐水平、低氧合指数及高乳酸水平是早期死亡的独立危险因素。3个指标构建的联合因子对早期死亡的预测有一定临床价值。

Objective:

To investigate the relevant risk factors affecting early mortality within 48 hours after initiating continuous renal replacement therapy (CRRT) in patients with septic acute kidney injury(AKI), and simultaneously evaluate the predictive value of these risk factors for early mortality.

Methods:

A retrospective analysis of clinical data was conducted on 258 patients with sepsis-related AKI who underwent CRRT in the Intensive Care Medicine Department of Beijing Friendship Hospital, Capital Medical University,from January 2016 to December 2021. Patients were divided into survival group (203 cases) and non-survival group (55cases) based on whether they died within 48 hours of CRRT initiation. Logistic regression was used to assess the risk factors of early death, and a combined prediction factor was constructed using logistic regression for independent risk factors. Receiver operating characteristic (ROC) curve analysis was performed to evaluate the predictive value of the combined prediction factor for early mortality.

Results

The early mortality rate of 258 patients with sepsis-related AKI receiving CRRT was 21.3%. Results from the multivariate logistic regression analysis indicate that lower creatinine levels [OR=1.50 (per 100 μmol/L decrease), 95% CI: 1.15-1.95], lower oxygenation index levels [OR=1.05 (per 10 mmHg decrease), 95% CI: 1.02-1.09], and elevated lactate levels [OR=1.20 (per 1 mmol/L increase), 95% CI: 1.10-1.30] were independent risk factors for early mortality in patients with septic AKI undergoing CRRT. A new combined prediction factor was generated through logistic regression, and the ROC curve analysis of the combined factor showed an AUC of 0.804 for predicting early mortality.

Conclusions

In patients with septic acute kidney injury undergoing continuous renal replacement therapy, low levels of creatinine and oxygenation index, as well as high lactate levels, have been identified as independent risk factors for early mortality. The composite factor derived from these three indicators demonstrates clinical utility in predicting early mortality.

图1 研究患者纳入流程图
图2 CRRT启动后随时间变化的患者死亡状况
图3 不同预测因子预测SAKI患者启动CRRT后早期死亡的ROC曲线
表1 CRRT启动前存活组与死亡组患者基线资料比较
指标 总人数(258 例) 存活组(203 例) 死亡组(55 例) Z /χ2/t 值 P 值
年龄(岁,xˉ±s) 65.4±18.2 65.7±18.6 64.2±14.6 t>=0.544 0.587
男性[ 例(%)] 164(63.6) 133(65.5) 31(56.3) χ 2=1.566 0.21
BMI(kg/m2xˉ±s) 23.9±4.5 24.0±4.3 23.6±5.1 t=0.613 0.541
查尔森合并症指数[MQ25Q75)] 2(1,3) 2(1,3) 1(1,2) Z=0.388 0.698
患者来源[ 例(%)]
 急诊入院 74(28.7) 65(32.0) 9(16.4) χ 2=5.186 0.023
 内科病房 94(36.4) 68(33.5) 26(47.3) χ 2=3.546 0.060
 外科病房 90(34.9) 70(34.5) 20(36.4) χ 2=0.067 0.795
患者入ICU 原因[ 例(%)]
 呼吸系统疾病 80(31.0) 69(34.0) 11(20.0) χ 2=3.959 0.047
 心血管系统疾病 26(10.1) 21(10.3) 5(9.1) χ 2=0.075 0.784
 消化系统疾病 80(31.0) 58(28.6) 22(40.0) χ 2=2.642 0.104
 肾脏系统疾病 23(8.9) 21(10.3) 2(3.6) χ 2=2.398 0.121
 血液系统疾病 24(9.3) 16(7.9) 8(14.5) χ 2=2.278 0.131
 其他疾病 25(9.7) 18(8.9) 7(12.7) χ 2=0.737 0.391
感染部位[ 例(%)]
 呼吸系统 147(57.0) 115(56.7) 32(58.2) χ 2=0.041 0.839
 腹腔系统 59(22.9) 48(23.6) 11(20.0) χ 2=0.326 0.568
 血行感染 14(5.4) 8(3.9) 6(10.9) χ 2=4.095 0.043
 泌尿系统 14(5.4) 12(5.9) 2(3.6) χ 2=0.436 0.509
 皮肤软组织 9(3.5) 9(4.4) 0 χ 2=2.527 0.112
 其他部位 15(5.8) 11(5.4) 4(7.3) χ 2=0.272 0.602
SOFA 评分(分,xˉ±s) 11.2±3.7 10.9±3.6 12.4±4.0 t=2.706 0.007
有创机械通气[ 例(%)] 178(69.0) 137(67.5) 41(74.5) χ 2=1.193 0.551
使用血管活性药[ 例(%)] 173(68.1) 126(63.3) 47(85.5) χ 2=9.723 0.002
CRRT 开始前24 h 尿量(ml) 480(246,849) 460(240,830) 645(370,1058) Z=1.875 0.061
CRRT 开始前累积液体平衡(ml,xˉ±s) 4271±3128 4132±3113 4793±3161 t=1.369 0.172
白细胞(109/ L) 12.1(7.1,19.3) 12.2(7.1,20.2) 11.4(6.2,15.2) Z=1.561 0.118
血红蛋白(g/L,xˉ±s) 91.1±24.2 88.3±22.1 91.8±24.8 t=0.971 0.333
血小板[×1012/L,M>Q25Q75)] 90.5(48.5,159.6) 94.0(52.0,164.0) 80.0(29.0,153.0) Z=1.442 0.149
血肌酐[μmol/L,MQ25Q75)] 244.3(148.8,384.5) 265.4(169.0,431.2) 167.6(120.1,257.3) Z=4.082 <0.001
白蛋白(g/L,xˉ±s) 25.81±4.55 26.07±4.43 24.9±4.91 t=1.678 0.277
血钾(mmol/L,xˉ±s) 4.6±0.8 4.6±0.7 4.7±0.8 t=0.795 0.427
碳酸氢根(mmol/L,xˉ±s) 21.6±6.9 21.5±6.2 21.8±9.0 t=0.278 0.781
氧合指数[mmHg,M>Q25Q75)] 179(121,267) 197(127,277) 140(94,202) Z=3.145 0.002
血乳酸[mmol/L,MQ25Q75)] 2.4(1.4,4.6) 1.7(1.3,3.5) 2.4(1.5,5.1) Z=5.403 <0.001
降钙素原[pg/ml,MQ25Q75)] 5.83(1.61,18.04) 5.70(1.47,18.16) 6.40(1.77,18.02) Z=0.387 0.699
氨基末端脑钠肽前体[pg/ml,M>Q25Q75)] 9771(2482,28978) 8870(2056,30000) 11030(3615,21772) Z=0.027 0.979
表2 Logistic回归分析SAKI接受CRRT后早期死亡的危险因素
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