脓毒性休克致急性肾损伤患者的危险因素分析

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^-2，t = 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。

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

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