成人ICU患者KDIGO-AKISCr标准进一步细化分型必要性探索:一项多中心前瞻性研究的二次分析  

Stratified outcomes of"Kidney Disease:Improving Global Outcomes"serum creatinine criteria in critical ill patients:a secondary analysis of a multicenter prospective study

作　　者：董桂英 秦君平 安友仲[3] 康焰[4] 于湘友[5] 赵鸣雁[6] 马晓春[7] 艾宇航[8] 许媛[9] 王玉山 钱传云[11] 吴大伟[12] 孙仁华[13] 李树生 胡振杰[15] 曹相原[16] 周发春[17] 姜利 林建东[19] 陈尔真 覃铁和[21] 何振扬[22] 周丽华[23] 杜斌[1] Dong Guiying;Qin Junping;An Youzhong;Kang Yan;Yu Xiangyou;Zhao Mingyan;Ma Xiaochun;Ai Yuhang;Xu Yuan;Wang Yushan;Qian Chuanyun;Wu Dawei;Sun Renhua;Li Shusheng;Hu Zhenjie;Cao Xiangyuan;Zhou Fachun;Jiang Li;Lin Jiandong;Chen Erzhen;Qin Tiehe;He Zhenyang;Zhou Lihua;Du Bin(Medical Intensive Care Unit,Peking Union Medical College Hospital,Beijing 100730,China;Medical Intensive Care Unit,Tsinghua University Affiliated Beijing Tsinghua Changueng Hospital,Beijing 102218,China;Department of Critical Care Medicine,Peking University People's Hospital,Beijing 100044,China;Department of Critical Care Medicine,West China Hospital,Sichuan University,Chengdu 610041,Sichuan,China;Department of Critical Care Medicine,First Affiliated Hospital,Xinjiang Medical University,Urumqi 830054,Xinjiang Uygur Autonomous Region,China;Department of Critical Care Medicine,the First Affiliated Hospital,Harbin Medical University,Harbin 150081,Heilongjiang,China;Department of Critical Care Medicine,the First Affiliated Hospital of China Medical University,Shenyang 110001,Liaoning,China;Department of Critical Care Medicine,Xiangya Hospital,Central South University,Changsha 410013,Hunan,China;Department of Critical Care Medicine,Beijing Tongren Hospital,Capital Medical University,Beijing 100005,China;Department of Emergency and Critical Care Medicine,the Second Hospital of Jilin University,Changchun 130000,Jilin,China;Department of Emergency Medicine and Medical Intensive Care Unit,the First Affiliated Hospital of Kunming Medical College,Kunming 650032,Yunnan,China;Department of Critical Care Medicine,Qilu Hospital,Shandong University,Jinan 250012,Shandong,China;Department of Critical Care Medicine,Zhejiang Provincial People's Hospital,Hangzhou 310014,Zhejiang,China;Department of Critical Care Medicine,Tongji Hospital,Tongji Medical College,Huazhong University of Science&Technology,Wuhan 430030,Hubei,China;Department of Critical Care Medicine,Hebei Medical University Fourth Hospital,Shijiazhuang 050011,Hebei,China;Department of Critical Care Medicin

机构地区：[1]中国医学科学院北京协和医学院北京协和医院MICU,北京100730 [2]清华大学附属北京清华长庚医院重症医学科,北京102218 [3]北京大学人民医院重症医学科,北京100044 [4]四川大学华西医院重症医学科,成都610041 [5]新疆医科大学第一附属医院重症医学科,乌鲁木齐830054 [6]哈尔滨医科大学第一附属医院重症医学科,哈尔滨150081 [7]中国医科大学第一附属医院重症医学科,沈阳110001 [8]中南大学湘雅医院重症医学科,长沙410013 [9]首都医科大学北京同仁医院重症医学科,北京100005 [10]吉林大学第二医院急诊与重症医学科,长春130000 [11]昆明医学院第一附属医院重症医学科,昆明650032 [12]山东大学齐鲁医院重症医学科,济南250012 [13]浙江省人民医院重症医学科,杭州310014 [14]华中科技大学同济医学院同济医院重症医学科,武汉430030 [15]河北医科大学第四医院重症医学科,石家庄050011 [16]宁夏医科大学附属医院重症医学科,银川750004 [17]重庆医科大学第一附属医院重症医学科,重庆400016 [18]首都医科大学宣武医院重症医学科,北京100038 [19]福建医科大学第一附属医院重症医学科,福州350005 [20]上海交通大学瑞金医院重症医学科,上海510370 [21]广东省人民医院重症医学科,广州510080 [22]海南省人民医院重症医学科,海口570311 [23]内蒙古医学院附属医院重症医学科,呼和浩特010050

出　　处：《中华危重病急救医学》2020年第3期313-318,共6页Chinese Critical Care Medicine

基　　金：中国医学科学院医学与健康科技创新工程项目(2016-12M-1-014)。

摘　　要：目的:探讨中国成人重症监护病房(ICU)患者按照改善全球肾脏病预后组织急性肾损伤诊断标准(KDIGO-AKI)分型临床结局的差异,分析影响ICU患者临床预后的危险因素。方法:对一项基于中国危重症临床试验组(CCCCTG)建立的危重症患者流行病学数据库中19个省市自治区22家三级甲等医院3063例ICU患者的多中心前瞻性研究进行二次分析。收集入选患者的人口学资料、ICU相关评分、检验检查结果及医疗过程等。将所有患者分为单纯AKI(PAKI)和慢性肾脏病发展AKI(AoCKD)两型,PAKI是指符合KDIGO-AKI的血肌酐(SCr)标准(KDIGO-AKISCr)且基线估算肾小球滤过率(eGFR)≥60 mL·min^-1·1.73 m^-2;AoCKD是指符合KDIGO-AKI SCr标准且基线eGFR为15~59 mL·min^-1·1.73 m^-2。以28 d内ICU全因病死率作为主要结局指标,ICU住院时间和肾脏替代治疗(RRT)比例作为次要结局指标。比较不同分型AKI患者基线资料和结局指标的差异;通过Kaplan-Meier生存曲线分析PAKI与AoCKD患者28 d内ICU累积存活率;采用Cox多因素分析筛选AKI患者28 d内ICU死亡的危险因素。结果:3063例患者中最终有1042例入选,其中AKI者345例,无AKI者697例,AKI发生率为33.11%;AKI患者28 d内ICU病死率为13.91%(48/345)。与PAKI患者(n=322)相比,AoCKD患者(n=23)年龄更大〔岁:74(59,77)比58(41,72)〕,基础肾功能更差〔eGFR(mL·min^-1·1.73 m^-2):49(38,54)比115(94,136)〕,入ICU病情更危重〔急性生理学与慢性健康状况评分Ⅱ(APACHEⅡ,分):23(19,27)比15(11,22)〕,基础合并症更多〔查尔森合并症指数(CCI):3(2,4)比0(0,1)〕,ICU住院期间SCr更高〔诊断AKI时SCr峰值(μmol/L):412(280,515)比176(124,340),均P<0.01〕;同时,AoCKD患者28 d内ICU病死率和RRT比例均明显高于PAKI患者〔39.13%(9/23)比12.11%(39/322),26.09%(6/23)比4.04%(13/322)〕,差异均有统计学意义(均P<0.01);然而AoCKD患者与PAKI患者的ICU住院时间比较差异则无统计学意义。Kaplan-Meier生存曲线分析结Objective To investigate the different outcomes of two types of acute kidney injury(AKI)according to standard of Kidney Disease:Improving Global Outcomes-AKI(KDIGO-AKI),and to analyze the risk factors that affect the prognosis of intensive care unit(ICU)patients in China.Methods A secondary analysis was performed on the database of a previous study conducted by China Critical Care Clinical Trial Group(CCCCTG),which was a multicenter prospective study involving 3063 patients in 22 tertiary ICUs in 19 provinces and autonomous regions of China.The demographic data,scores reflecting severity of illness,laboratory findings,intervention during ICU stay were extracted.All patients were divided into pure AKI(PAKI)and acute on chronic kidney disease(AoCKD).PAKI was defined as meeting the serum creatinine(SCr)standard of KDIGO-AKI(KDIGO-AKISCr)and the estimated glomerular filtration rate(eGFR)at baseline was≥60 mL·min^-1·1.73 m^-2,and AoCKD was defined as meeting the KDIGO-AKISCr standard and baseline eGFR was 15-59 mL·min^-1·1.73 m^-2.All-cause mortality in ICU within 28 days was the primary outcome,while the length of ICU stay and renal replacement therapy(RRT)were the secondary outcome.The differences in baseline data and outcomes between the two groups were compared.The cumulative survival rate of ICU within 28 days was analyzed by Kaplan-Meier survival curve,and the risk factors of ICU death within 28 days were screened by Cox multivariate analysis.Results Of the 3063 patients,1042 were enrolled,345 with AKI,697 without AKI.The AKI incidence was 33.11%,while ICU mortality within 28 days of AKI patients was 13.91%(48/345).Compared with PAKI patients(n=322),AoCKD patients(n=23)were older[years old:74(59,77)vs.58(41,72)]and more critical when entering ICU[acute physiology and chronic health evaluationⅡ(APACHEⅡ)score:23(19,27)vs.15(11,22)],had worse basic renal function[eGFR(mL·min^-1·1.73 m^-2):49(38,54)vs.115(94,136)],more basic complications[Charlson comorbidity index(CCI):3(2,4)vs.0(0,1)]and higher SCr dur

关 键 词：急性肾损伤 改善全球肾脏病预后组织 血肌酐标准 重症监护病房 病死率 

分 类 号：R692[医药卫生—泌尿科学] R45[医药卫生—外科学]