重症监护病房住院患者院内获得性急性肾损伤的临床研究

发布时间：2018-08-13 09:38

【摘要】：目的:急性肾损伤(acute kidney injury,AKI)是危重患者的常见并发症之一,增加了重症监护病房(intensive care unit,ICU)住院患者的病死率,导致了沉重的医疗负担。本研究收集ICU内发生院内获得性急性肾损伤(hospital-acquired acute kidney injury,HA-AKI)并发症患者的临床资料,分析其临床特点及预后情况。了解本地区综合性三级医院ICU住院患者HA-AKI的发病率、病因构成、治疗措施及预后情况,初步探讨ICU住院患者并发HA-AKI的危险因素及影响预后的危险因素,为临床积极预防急性肾损伤的发生、早期诊断并采取有效的治疗措施提供依据。方法:采用回顾性分析的方法,收集医院2014年1月1日至2015年12月31日两年中入住ICU的1317例患者的临床资料,根据2012-年改善全球肾病预后组织(Kidney Disease:Improving Global Outcomes,KDIGO)制定的AKI诊断及分期标准筛选出符合纳入标准的病例,记录其一般情况、既往史、临床特征及患者在入院/ICU时、出现HA-AKI时和出院/死亡前的相关实验室检测指标、预后情况(以出院或院内死亡为研究终点记录患者的临床转归)。根据患者预后将纳入的病例分为死亡组、肾功能部分恢复组及完全恢复组,对HA-AKI发生前后、完全恢复组及死亡组的各项参数进行比较。正态分布的计量资料使用均数±标准差(?X±S)表示,采用两独立样本t检验;非正态分布的计量资料使用Median(P25,P75)表示,采用两独立样本秩和检验;计数资料以绝对值或构成比表示,两组间比较采用χ2检验,两因素的相关性分析采用线性相关分析,多因素采用Logistic回归分析方法。使用SPSS17.0统计软件对所有数据进行分析。结果:1.两年中共有1317例患者入住ICU,HA-AKI患者共188例,发病率为14.27%;其中AKI 1期组103例(54.79%),AKI 2期组35例(18.61%),AKI 3期组50例(26.60%);AKI分期越高,患者感染性休克发生率、器官衰竭数、机械通气使用率、血管活性药物使用率、急性生理学与慢性健康状况评分系统Ⅱ(Acute physiology and chronic health evaluationⅡ,APACHEⅡ)评分越高(P0.05)。2.HA-AKI原发病前三位分别是:感染(n=70,37.2%),外伤性疾病(n=62,32.9%),脑血管意外(n=23,12.2%);按病变部位分析病因:其中肾前性86例(45.7%),主要原因为外伤出血,其次为心力衰竭。肾性95例(50.6%),脓毒症为首要病因(53例,55.8%);肾后性7例(3.7%),主要病因为泌尿系统结石、腹盆腔肿瘤等。按年龄分析病因:中青年组(年龄60岁)77例,以肾性病因为主,占71.7%,年龄60岁的老年组有111例,以肾前性病因为主,占58.6%;通过组间比较显示老年组以肾前性及肾后性病因为主,中青年组以肾性病因为主,差异有统计学意义(P0.05)。3.188例HA-AKI死亡患者87例,病死率46.28%,其中AKI 1期组36例(34.9%),AKI 2期组18例(51.4%),AKI 3期组33例(66.0%)。AKI分期越高,病死率越高。按年龄分析:中青年组死亡率(n=24,31.2%)显著低于老年组死亡率(n=63,56.8%)(P0.01)。4.HA-AKI患者死亡风险增加的因素有:年龄(≥60岁)(χ2=3.4571,P0.05)、脓毒症性休克(χ2=21.3214,P0.01)、器官衰竭数目2(χ2=17.5710,P0.01)、机械通气(χ2=23.6574,P0.01)、低血压(χ2=30.5709,P0.01)、APACHEⅡ评分(20分)(χ2=14.6431,P0.01)。5.ICU患者并发HA-AKI的独立危险因素:机械通气、脓毒症性休克。结论:ICU住院患者并发HA-AKI的发病率及病死率均较高。AKI分期越高,患者年龄越大,病死率越高。HA-AKI的原发病前三位依次是:感染、严重外伤、脑血管意外。年龄(60岁)、脓毒症休克、APACHEⅡ评分(20分)、机械通气、低血压史、肾外器官衰竭数2是与HA-AKI预后相关的危险因素。机械通气、脓毒症性休克是HA-AKI发生的独立危险因素。
[Abstract]:Objective: Acute kidney injury (AKI) is one of the common complications in critically ill patients, which increases the fatality rate of inpatients in intensive care unit (ICU) and leads to heavy medical burden. To investigate the incidence, etiology, treatment and prognosis of HA-AKI in ICU inpatients of general tertiary hospitals in this region, and to explore the risk factors and prognostic factors of HA-AKI in ICU inpatients, so as to prevent acute kidney injury. Methods: The clinical data of 1317 patients admitted to ICU from January 1, 2014 to December 31, 2015 were retrospectively analyzed. The data were based on the Kidney Disease: Improving Global Outcomes (KDIGO) system from 2012 to December 31, 2015. AKI diagnostic criteria and staging criteria were used to screen patients who met the inclusion criteria and record their general condition, past history, clinical characteristics, laboratory test indicators at the time of HA-AKI onset and before discharge/death, and prognosis (with discharged or in-hospital deaths as the end point of study to record clinical outcomes). The patients were divided into death group, partial recovery group and complete recovery group. The parameters of HA-AKI before and after the occurrence of HA-AKI were compared with those of the death group. 5) Two independent sample rank sum test was used; the counting data were expressed by absolute value or composition ratio. _2 test was used for comparison between the two groups. Linear correlation analysis was used for correlation analysis of the two factors, and logistic regression analysis was used for multiple factors. A total of 188 patients (14.27%) with HA-AKI were admitted to ICU, including 103 patients (54.79%) in AKI stage 1 group, 35 patients (18.61%) in AKI stage 2 group and 50 patients (26.60%) in AKI stage 3 group. The first three primary diseases of HA-AKI were infection (n=70,37.2%), traumatic disease (n=62,32.9%) and cerebrovascular accident (n=23,12.2%). Ninety-five cases (50.6%) were renal, 53 cases (55.8%) were sepsis, 7 cases (3.7%) were postrenal, the main causes were urinary calculi, abdominal and pelvic tumors, etc. The comparison showed that pre-renal and post-renal causes were predominant in the elderly group, and renal causes were predominant in the young and middle-aged group. The difference was statistically significant (P 0.05). 3.188 patients died of HA-AKI, with a fatality rate of 46.28%. Among them, 36 (34.9%) were in the AKI stage 1 group, 18 (51.4%) in the AKI stage 2 group, and 33 (66.0%) in the AKI stage 3 group. The mortality rate in young and middle-aged group (n = 24,31.2%) was significantly lower than that in elderly group (n = 24,31.2%) (n = 63,56.8%) (P 0.01). 4. The risk factors for increased mortality in HA-AKI patients were age (>60 years) (962 = 3.4571, P 0.05), septicshock (962 = 21.3214, P 0.01), septicshock (962 = 21.3214, P 0.01), number of organfailure (962 = 17.5710, P 0.01), mechanical ventiventiventiventiventi (962 = 23.74, P 0.01), hypotblood pressure (962 = 23.74, P 0.01), hypotblood pressure (962 = 30.30.01, P 0 In the meantime, it is necessary to study the relationship between the two. The independent risk factors of HA-AKI in ICU patients were mechanical ventilation and septic shock. Conclusion: The morbidity and mortality of HA-AKI in ICU inpatients were higher. The higher the AKI stage, the older the patients, the higher the mortality. The first three HA-AKI cases were infection, severe trauma, septic shock. Age (60 years), septic shock, APACHE II score (20 points), mechanical ventilation, history of hypotension, and number of extrarenal organ failure 2 were risk factors associated with the prognosis of HA-AKI. Mechanical ventilation and septic shock were independent risk factors for HA-AKI.
【学位授予单位】：西南医科大学
【学位级别】：硕士
【学位授予年份】：2017
【分类号】：R692.5

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