摘要
目的：探讨肾脏替代治疗（RRT）中液体平衡及RRT模式对脓毒性急性肾损伤（AKI）患者肾功能和预后的影响。方法采用回顾性队列研究方法，选择2009年1月至2014年12月南京医科大学第二附属医院接受RRT的117例脓毒性AKI患者，根据RRT开始后1周内液体出入总量将患者分为液体正平衡组（52例）及液体负平衡组（65例），以60 d肾功能恢复率及病死率作为终点事件。RRT模式包括连续性肾脏替代治疗（CRRT）及间歇性肾脏替代治疗（IRRT）。采用Cox比例风险模型分析RRT前肾小球滤过率（eGFR）、序贯器官衰竭评分（SOFA）、RRT模式、RRT前液体过量、RRT中液体负平衡等因素对肾功能恢复及预后的影响。结果两组患者临床特征无明显差异，液体负平衡组行CRRT的患者略多于液体正平衡组（52.31%比36.54%，χ^2＝2.899，P＝0.089）。Kaplan-Meier生存曲线分析结果显示，液体负平衡组患者60 d肾功能恢复率明显增加（χ^2＝4.803，P＝0.028），病死率显著下降（χ^2＝9.505，P＝0.002）。液体负平衡组60 d肾功能恢复率明显高于液体正平衡组（47.69%比28.85%，χ^2＝3.991，P＝0.046），病死率明显低于液体正平衡组（40.00%比67.31%，χ^2＝4.378，P＝0.036）。采用Cox多变量回归分析以排除混杂因素，经多个临床变量调整后，RRT中液体负平衡始终是肾功能恢复及死亡的影响因素〔风险比（HR）＝2.440，95%可信区间（95%CI）＝1.089～5.464， P＝0.030；HR＝0.443，95%CI＝0.238～0.822，P＝0.010〕；RRT前较高的eGFR和CRRT模式是促进肾功能恢复的独立因素（HR＝1.014，95%CI＝1.003～1.026，P＝0.012；HR＝3.138，95%CI＝1.765～7.461，P＝0.002）；SOFA评分是患者死亡的独立危险因素（HR＝1.115，95%CI＝1.057～1.177，P＜0.001）。结论脓毒性AKI患者一旦出现液体过量，及时进行RRT有效清除其体内多余的液体可能逆转不良预后，RRT中液体负平衡有利于脓毒性AKI患者肾功能的恢复及病死率的降低，其中CRRT模式是一个较好的选择。
ObjectiveTo investigate the influence of fluid balance and model of renal replacement therapy （RRT） on renal function and prognosis of patients suffering from septic acute kidney injury （AKI）.Methods A retrospective cohort analysis of 117 septic AKI patients who had undergone RRT between January 2009 and December 2014 was performed in the Second Affiliated Hospital of Nanjing Medical University. The patients were divided into positive fluid balance group （n = 52） and negative fluid balance group （n = 65） according to the total amount of fluid calculated from the difference between fluid administered and fluid lost during the first 1 week of RRT. The incidence of renal recovery and death of the patients by 60 days as the endpoint events were taken to judge the prognosis of two groups. RRT strategies included continuous renal replacement therapy （CRRT） and intermittent renal replacement therapy （IRRT）. Multiple factors including estimated glomerular filtration rate （eGFR）, sequential organ failure assessment （SOFA） score, RRT model, the accumulation of fluid before initiation of RRT, and negative fluid balance during RRT were analyzed for outcome predictors by Cox proportional hazards model.Results There were no differences between two groups regarding clinical characteristics. The percentage of receiving CRRT in the negative fluid balance group was slightly higher than that of the positive fluid balance group （52.31% vs. 36.54%,χ^2 = 2.899,P = 0.089）. With Kaplan-Meier survival curves, it was shown that the patients of negative fluid balance group had a higher rate of recovery of renal function （χ^2 = 4.803,P = 0.028） and significantly lower mortality rate （χ^2 = 9.505, P = 0.002）. The rate of recovery of renal function by 60 days was higher in the negative fluid balance group than that in the positive fluid balance group （47.69% vs. 28.85%,χ^2 = 3.991,P = 0.046）, while the mortality rate was significantly lowered in the negative fluid balance group compared with that of the positive fluid balance group （40.00% vs. 67.31%,χ^2 = 4.378,P = 0.036）. Cox multivariate regression was used for excluding confounding factors. After adjusting for the clinically relevant variables, RRT negative fluid balance was significantly associated with recovery of renal function [hazard ratios （HR） = 2.440, 95% confidence intervals （95%CI） = 1.089-5.464,P = 0.030] and mortality （HR = 0.443, 95%CI = 0.238-0.822,P = 0.010]. Higher eGFR before RRT and CRRT were independent favorable factors for recovery of renal function （HR= 1.014, 95%CI = 1.003-1.026,P = 0.012;HR = 3.138, 95%CI = 1.765-7.461,P = 0.002）, and higher SOFA score was associated with a significantly higher risk of death （HR = 1.115, 95%CI = 1.057-1.177, P〈 0.001）.ConclusionsOnce the patients with septic AKI showed the signs of fluid overload, timely RRT and effective removal of excessive liquid may reverse the adverse prognosis. RRT with negative fluid balance is beneficial for the recovery of renal function, and reduce the mortality in patients with septic AKI, and CRRT model is a good choice.
出处
《中华危重病急救医学》
CAS
CSCD
北大核心
2015年第5期321-326,共6页
Chinese Critical Care Medicine
基金
基金项目：国家自然科学基金（31171093）
江苏省临床医学科技专项重点病种的规范化诊疗研究（BL2013037）
关键词
液体平衡
脓毒症
肾损伤
急性
连续性肾脏替代治疗
间歇性肾脏替代治疗
Fluid balance
Sepsis
Acute kidney injury
Continuous renal replacement therapy
Intermittent renal replacement therapy
