ICU病房医院获得性急性肾损伤相关临床因素的探讨

目的探讨ICU病房医院获得性急性肾损伤（AKI）相关的危险因素、临床特点及预后。方法回顾分析我院ICU病房48例行肾脏替代治疗（RRT）的合并多器官功能障碍综合征（MODS）的AKI患者，以AKI发生时间分为医院获得性AKI组（HA-AKI）（13例，入院时肾功能正常，入院48h后发生AKI）和社区获得性AKI组（CA-AKI）（35例，入院时即存在或48h内发生AKI）。观察比较两组在一般情况、脏器衰竭、机械通气、肾脏替代治疗（RRT）及预后的不同。结果HA．AKI组平均年龄大于CA．AKI组（P=0．022），CA-AKI组前三位原发病分别为严重感染（42．8％）、慢性肾脏疾病（CKD）并发AKI（11．4％）及多发伤（不伴头外伤）（8．6％），HA-AKI组严重感染仍占首位（30．8％），其次为脑卒中（23．1％，P=0．024）、多发伤伴头外伤（15．4％，P=0．018）及消化道出血（15．4％）；HA-AKI组发生4个以上脏器功能衰竭占84．6％，明显高于CA-AKI组65．7％（P=0．000）；HA．AKI组第1天血钠（P=0．036）及HC03水平（P=0．001）明显高于CA-AKI组，且尿量偏多（P=0．046）；HA-AKI组尿素氮（BUN）进行性增高，到第7天BUN水平明显高于第1天（P=0．015），而CA-AKI组患者入院后7d内Cr及BUN变化不明显，但第7天血钠有所升高（P=0．023）、HCO，改善（P=0．030）；虽然HA．AKI组入院24hAPACHEⅢ评分明显低于CA-AKI组[（53．2±22．8）分与（89．1±25．7）分，P=0．000），住院时间、ICU住院时间及机械通气时间较CA-AKI组明显延长（P〈0．05），但两组患者行RRT治疗次数、转归及肾功能恢复情况比较差异均无统计学意义（P均〉0．05）。结论入院24hAPACHEⅢ评分不能准确反映合并HA-AKI的MODS患者的预后，HA-AKI在年龄、原发病、脏器功能改变等方面与CA-AKI明显不同。

Related clinical factors of hospital-acquired acute renal injury in intensive care unite

Objective To investigate the related risk factors,clinical features and prognosis of hospital- acquired acute kidney injury （AKI） in intensive care unit （ICU）. Methods We retrospectively analyzed 48 patients with both acute kidney injury and multiple organ dysfunction syndrome （MODS）, who received renal replacement therapy from October 2006 to February 2011 in our ICU. According to whether the occurrence time of AKI was 48 hours after admission, they were divided into hospital-acquired AKI （HA-AKI） group and community-acquired AKI （CA-AKI） group, with 13 and 35 cases respectively. We compared the differences between these two groups in gender, age,acute physiology and chronic health evaluation HI （APACHE III ）, primary diseases, days of mechanical ventilation, times of renal replacement therapy, number and indicators of organ failure,prognosis,renal function recovery, length of stay in ICU and hospital. Results The mean age of HA-AKI group is （64. 5±21.4） years, which is older than that in CA-AKI group （50.2±17. 5 ） years （ P = 0. 022）. The top three primary diseases in CA-AKI group are severe infection（42. 8% ） ,chronic kidney disease （CKD） concurrency of AKI （11.4%）and multiple trauma without head injury （8.6%）. However severe infection still occupies the first in HA-AKI group （ 30. 8% ）, followed by stroke （ 23.1%, P = 0. 024）, multiple trauma with head injury（ 15.4% ,P = 0. 018） and gastrointestinal bleeding（ 15.4% ） ;Patients in HA-AKI group with more than four organ failures account for 84.6% ,significantly higher than 65.7% in CA-AKI group （P = 0. 000）. On the first day, the levels of serum sodium （P = 0. 036 ）and bicarbonate （P = 0. 001 i）in HA-AKI group are higher than that in CA-AKI group, and the urinary volume is more （P = 0. 046）. In HA-AKI group, the level of urea nitrogen on the seven day increases so progressively that it becomes significantly higher than that onthe first day（P =0. 015） ,but in CA-AKI group,there is no significant change in the levels of serum creatinine and urea nitrogen after AKI, while the levels of serum sodium （ P = 0. 023 ） and bicarbonate （ P = 0. 030） increase significantly; APACHE III score in HA-AKI group after admission 24 hours is significantly lower than that in CA- AKI group（53.2±22. 8） point vs （89. 1±25.7） point,P =0. 000） ,and the length of stay in ICU and hospital and days of mechanical ventilation in HA-AKI group are significantly longer than that in CA-AKI group, but there are no significant differences in times of RRT therapy, prognosis and recovery of renal function. Conclusion APACHE HI score after 24 hours of admission does not accurately reflect the prognosis of patients with MODS and HA-AKI. There are great differences in age, primary diseases, organ function changes and other aspects of HA-AKI when compared with CA-AKI.