中华危重病急救医学
中華危重病急救醫學
중화위중병급구의학
Chinese Critical Care Medicine
2015年
5期
321-326
,共6页
孙治平%孙伏喜%牛常明%沈霞%叶红%曹红娣
孫治平%孫伏喜%牛常明%瀋霞%葉紅%曹紅娣
손치평%손복희%우상명%침하%협홍%조홍제
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
液體平衡%膿毒癥%腎損傷,急性%連續性腎髒替代治療%間歇性腎髒替代治療
액체평형%농독증%신손상,급성%련속성신장체대치료%간헐성신장체대치료
Fluid balance%Sepsis%Acute kidney injury%Continuous renal replacement therapy%Intermittent renal replacement therapy
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%，χ2＝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（χ2＝4.803，P＝0.028），病死率显著下降（χ2＝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%，χ2＝3.991，P＝0.046），病死率明显低于液体正平衡组（40.00%比67.31%，χ2＝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。
目的：探討腎髒替代治療（RRT）中液體平衡及RRT模式對膿毒性急性腎損傷（AKI）患者腎功能和預後的影響。方法採用迴顧性隊列研究方法，選擇2009年1月至2014年12月南京醫科大學第二附屬醫院接受RRT的117例膿毒性AKI患者，根據RRT開始後1週內液體齣入總量將患者分為液體正平衡組（52例）及液體負平衡組（65例），以60 d腎功能恢複率及病死率作為終點事件。RRT模式包括連續性腎髒替代治療（CRRT）及間歇性腎髒替代治療（IRRT）。採用Cox比例風險模型分析RRT前腎小毬濾過率（eGFR）、序貫器官衰竭評分（SOFA）、RRT模式、RRT前液體過量、RRT中液體負平衡等因素對腎功能恢複及預後的影響。結果兩組患者臨床特徵無明顯差異，液體負平衡組行CRRT的患者略多于液體正平衡組（52.31%比36.54%，χ2＝2.899，P＝0.089）。Kaplan-Meier生存麯線分析結果顯示，液體負平衡組患者60 d腎功能恢複率明顯增加（χ2＝4.803，P＝0.028），病死率顯著下降（χ2＝9.505，P＝0.002）。液體負平衡組60 d腎功能恢複率明顯高于液體正平衡組（47.69%比28.85%，χ2＝3.991，P＝0.046），病死率明顯低于液體正平衡組（40.00%比67.31%，χ2＝4.378，P＝0.036）。採用Cox多變量迴歸分析以排除混雜因素，經多箇臨床變量調整後，RRT中液體負平衡始終是腎功能恢複及死亡的影響因素〔風險比（HR）＝2.440，95%可信區間（95%CI）＝1.089～5.464， P＝0.030；HR＝0.443，95%CI＝0.238～0.822，P＝0.010〕；RRT前較高的eGFR和CRRT模式是促進腎功能恢複的獨立因素（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評分是患者死亡的獨立危險因素（HR＝1.115，95%CI＝1.057～1.177，P＜0.001）。結論膿毒性AKI患者一旦齣現液體過量，及時進行RRT有效清除其體內多餘的液體可能逆轉不良預後，RRT中液體負平衡有利于膿毒性AKI患者腎功能的恢複及病死率的降低，其中CRRT模式是一箇較好的選擇。
목적：탐토신장체대치료（RRT）중액체평형급RRT모식대농독성급성신손상（AKI）환자신공능화예후적영향。방법채용회고성대렬연구방법，선택2009년1월지2014년12월남경의과대학제이부속의원접수RRT적117례농독성AKI환자，근거RRT개시후1주내액체출입총량장환자분위액체정평형조（52례）급액체부평형조（65례），이60 d신공능회복솔급병사솔작위종점사건。RRT모식포괄련속성신장체대치료（CRRT）급간헐성신장체대치료（IRRT）。채용Cox비례풍험모형분석RRT전신소구려과솔（eGFR）、서관기관쇠갈평분（SOFA）、RRT모식、RRT전액체과량、RRT중액체부평형등인소대신공능회복급예후적영향。결과량조환자림상특정무명현차이，액체부평형조행CRRT적환자략다우액체정평형조（52.31%비36.54%，χ2＝2.899，P＝0.089）。Kaplan-Meier생존곡선분석결과현시，액체부평형조환자60 d신공능회복솔명현증가（χ2＝4.803，P＝0.028），병사솔현저하강（χ2＝9.505，P＝0.002）。액체부평형조60 d신공능회복솔명현고우액체정평형조（47.69%비28.85%，χ2＝3.991，P＝0.046），병사솔명현저우액체정평형조（40.00%비67.31%，χ2＝4.378，P＝0.036）。채용Cox다변량회귀분석이배제혼잡인소，경다개림상변량조정후，RRT중액체부평형시종시신공능회복급사망적영향인소〔풍험비（HR）＝2.440，95%가신구간（95%CI）＝1.089～5.464， P＝0.030；HR＝0.443，95%CI＝0.238～0.822，P＝0.010〕；RRT전교고적eGFR화CRRT모식시촉진신공능회복적독립인소（HR＝1.014，95%CI＝1.003～1.026，P＝0.012；HR＝3.138，95%CI＝1.765～7.461，P＝0.002）；SOFA평분시환자사망적독립위험인소（HR＝1.115，95%CI＝1.057～1.177，P＜0.001）。결론농독성AKI환자일단출현액체과량，급시진행RRT유효청제기체내다여적액체가능역전불량예후，RRT중액체부평형유리우농독성AKI환자신공능적회복급병사솔적강저，기중CRRT모식시일개교호적선택。
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%,χ2 = 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 (χ2 = 4.803,P = 0.028) and significantly lower mortality rate (χ2 = 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%,χ2 = 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%,χ2 = 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.
