CAJ | 학술논문

目的探讨急性肾损伤网络(AKIN)制定的急性肾损伤(AKI)诊断标准联合急性生理与慢性健康状况评分Ⅱ(APACHE Ⅱ)和序贯器官衰竭评估(SOFA)评分对心脏术后AKI的预后评估价值.方法前瞻性收集2009年4月至8月期间在本院行心脏手术患者的临床资料,采用AKIN标准准心脏术后患者进行AKI诊断和分期;根据患者术后第1个24 h内的生理指标最差值进行APACHEⅡ和SOFA评分,并用受试者工作特征(ROC)曲线和Hosmer-Lemeshow拟合优度榆验评价3项评估系统的分辨力和校准力.以Logistic多元回归分析它们对预后的影响.结果　 993例患者中309例术后出现AKI,发病率为31.1%.患者AKI诊断日和首次达AKIN最高分期日距手术的中位间隔时间分别为1 d和2 d.AKIN 1、2、3期患者的APACHE Ⅱ及SOFA评分均高于非AKI患者(P<0.01),且分值与AKIN分期呈正相关(APACHEⅡr=0.37,P<0.01;SOFA r=0.42,P<0.01).病死率亦随AKIN分期升高而升高.非AKI组、AKIN 1期患者根据APACHE Ⅱ分值计算所得的校正预计病死率(PDR.A)明显高于实际病死率(P<0.01),而AKIN 3期PDR-A则低于实际病死率(P<0.01).APACHE Ⅱ、SOFA评分及AKIN分期的ROC曲线下面积(AUC)均>0.8,且Hosmer-Lemeshow拟合优度检验提示模型拟合较好.Logistic多元回归分析显示APACHE Ⅱ≥19(OR=4.26)和AKIN 3期(OR=76.15)是心脏术后患者院内死亡的独立预测指标.结论 AKIN标准能在心脏术后早期对患者进行AKI诊断和分期,且在一定程度上发挥预后评估的作用.APACHE Ⅱ和SOFA在术后第1个24 h内的评分能较好区分病情的严重程度.3 者作为预测模型均显示了对于整体预后较好的分辨力和校准力,且APACHE Ⅱ≥19和AKIN 3期是心脏术后患者院内死亡的独立预测指标.需注意APACHEⅡ计算所得的PDR-A与AKIN不同分期组实际病死率相比存在偏差,动态评分町能有助于提高预测准确性.
목적 탐토급성신손상망락(AKIN)제정적급성신손상(AKI)진단표준연합급성생리여만성건강상황평분Ⅱ(APACHE Ⅱ)화서관기관쇠갈평고(SOFA)평분대심장술후AKI적예후평고개치.방법 전첨성수집2009년4월지8월기간재본원행심장수술환자적림상자료,채용AKIN표준준심장술후환자진행AKI진단화분기;근거환자술후제1개24 h내적생리지표최차치진행APACHEⅡ화SOFA평분,병용수시자공작특정(ROC)곡선화Hosmer-Lemeshow의합우도유험평개3항평고계통적분변력화교준력.이Logistic다원회귀분석타문대예후적영향.결과　 993례환자중309례술후출현AKI,발병솔위31.1%.환자AKI진단일화수차체AKIN최고분기일거수술적중위간격시간분별위1 d화2 d.AKIN 1、2、3기환자적APACHE Ⅱ급SOFA평분균고우비AKI환자(P<0.01),차분치여AKIN분기정정상관(APACHEⅡr=0.37,P<0.01;SOFA r=0.42,P<0.01).병사솔역수AKIN분기승고이승고.비AKI조、AKIN 1기환자근거APACHE Ⅱ분치계산소득적교정예계병사솔(PDR.A)명현고우실제병사솔(P<0.01),이AKIN 3기PDR-A칙저우실제병사솔(P<0.01).APACHE Ⅱ、SOFA평분급AKIN분기적ROC곡선하면적(AUC)균>0.8,차Hosmer-Lemeshow의합우도검험제시모형의합교호.Logistic다원회귀분석현시APACHE Ⅱ≥19(OR=4.26)화AKIN 3기(OR=76.15)시심장술후환자원내사망적독립예측지표.결론 AKIN표준능재심장술후조기대환자진행AKI진단화분기,차재일정정도상발휘예후평고적작용.APACHE Ⅱ화SOFA재술후제1개24 h내적평분능교호구분병정적엄중정도.3 자작위예측모형균현시료대우정체예후교호적분변력화교준력,차APACHE Ⅱ≥19화AKIN 3기시심장술후환자원내사망적독립예측지표.수주의APACHEⅡ계산소득적PDR-A여AKIN불동분기조실제병사솔상비존재편차,동태평분정능유조우제고예측준학성.
Objective To explore the prognostic value of Acute Kidney Injury Network (AKIN)criteria combined with Acute Physiology and Chronic Health Evaluation Ⅱ (APACHE Ⅱ)and Sequential Organ Failure Assessment(SOFA)scoring system in acute kidney injury(AKI)after cardiac surgery. Methods Clinical data of patients who underwent open-heart surgery in Zhongshan Hospital,Fudan University from April 2009 to August 2009 were prospectively collected.AKI after cardiac surgery was classified by AKIN staging system.APACHE Ⅱ and SOFA scores were evaluated according to the worst value of physiologic variables in the 1st 24 h after surgery.Discrimination and calibration of these three models were assessed by receiver operating characteristic(ROC) curve and Hosmer-Lemeshow goodness-of-fit test.Besides,their effects on inhospital mortality were evaluated by multivariate Logistic regression analysis. Results Of the 993 admissions,309 patients developed AKI and the incidence was 31.1%.The median time that developed postoperative AKI and reached the Scr peak were 1 d and 2 d respectively.Either APACHE Ⅱ or SOFA scores,which was positively correlted with the severity of AKI(APACHEⅡr=0.37,P<0.01;SOFA r=0.42,P<0.01)was higher in AKI patients compared with that in nonAKI patients(P<0.01).The mortality rose corresponding to the severity of kidney injury.However,the predicted death rate-adjusted(PDR-A)calculated by APACHE Ⅱ scoreS Was higher than the actual value in non-AKI patients and AKIN stage 1(P<0.01),while it was lower in AKIN stage 3 (P<0.01).The areas under the ROC curve of APACHEⅡ,SOFA and AKIN criteria were all above 0.8 and the results of Hosmer-Lemeshow goodness-of-fit test indicated good calibration of three models.Multivariate analysis showed that APACHE Ⅱ≥19(OR=4.26)and AKIN stage 3(OR=76.151 were independent predictors of in-hospital mortality. Conclusions AKI can be classified by AKIN criteria in the early stage after cardiac surgery and the AKIN staging system may serve the prediction of prognosis.The APACHE Ⅱ and SOFA scores just evaluated in the 1st 24 h after operation can discern the severity of patients'illness.Three models all present good discrimination and calibration in predicting patients'outcome.APACHE Ⅱ≥19 along with AKIN stage 3 are found to be the independent predictors of in-hospital mortality.It should be noticed that the deviation between PDR-A and the actual mortality in subgroups,dynamic evaluation may raise the accuracy of scoring system.