危重症孕产妇并发急性肾损伤的危险因素分析

目的了解危重症孕产妇并发急性肾损伤(AKI)的临床特征及预后情况,并分析其相关危险因素。方法回顾性分析90例危重症孕产妇并发AKI患者的病案资料作为AKI组,同时选取90例非AKI危重症孕产妇作为对照。对比两组流行病学及临床资料,多因素Logistic回归分析危重症孕产妇并发AKI的相关危险因素。结果 AKI组孕产妇平均年龄(31. 85±5. 35)岁,患者原发病中子痫或子痫前期患者最多,共49例(54. 4%)。高血压62例(84. 4%),全身炎症反应综合征(SIRS) 59例(65. 6%),凝血异常47例(52. 2%),休克51例(56. 7%)。AKI组急性生理与慢性健康评分系统Ⅱ(APACHEⅡ)平均分(16. 16±3. 41)分,与非AKI组平均分(8. 22±4. 54)分对比,差异均有统计学意义(均P0. 05)。多因素回归分析,AKI组高血压症状、SIRS、凝血异常、休克及APACHEⅡ评分高于7分,与对照组比较,差异均有统计学意义(均P0. 05)。结论危重症孕产妇并发急性肾功能损伤,加重患者病情危重症程度,增加病死率,高血压症状、SIRS、凝血异常、休克及APACHEⅡ评分高是主要危险因素。     

失代偿期肝硬化患者医院感染的危险因素探讨

目的探讨失代偿期肝硬化患者医院感染的危险因素,以控制和预防感染的发生,改善患者预后。方法回顾性分析150例失代偿期肝硬化住院患者临床资料,总结医院感染相关危险因素,采用SPSS13.0软件进行数据分析,将患者年龄、性别、肝功能分级、血清白蛋白、白细胞计数、有无侵入性操作史、有无抗病毒治疗、住院时间作为自变量,是否并发感染为因变量,进行单因素logistic回归分析。结果 150例患者发生医院感染32例,感染率21.3%,失代偿期肝硬化患者医院感染主要类型有呼吸道感染、自发性细菌性腹膜炎;细菌培养共分离病原菌24株,主要病原菌依次为大肠埃希菌、肺炎克雷伯菌、肺炎链球菌、白色假丝酵母菌;感染患者多有肝功能分级高、白细胞计数低、低蛋白血症、侵入性操作史、住院时间长、未进行彻底抗病毒治疗等危险因素;多因素回归分析显示,肝功能分级、抗病毒治疗、侵入性操作及住院时间是影响失代偿期肝硬化患者医院感染的独立危险因素(P<0.05)。结论失代偿期肝硬化患者医院感染与多种因素相关,在患者治疗过程中应引起重视,以预防和减少感染的发生。     

劳力性热射病发生急性肾损伤的危险因素分析

目的:探讨影响劳力性热射病（EHS）发生急性肾损伤（AKI）的危险因素。方法:于2019年11月,回顾2015年7月至2019年9月期间收治的69例EHS患者的临床资料。收集患者的一般资料、实验室指标、入院时的格拉斯哥评分（GCS）、24小时急性生理与慢性健康评分Ⅱ（APACHE Ⅱ）、接触时间率和体力劳动强度。患者按...     

肝硬化失代偿期患者真菌感染多因素分析

目的探讨肝硬化失代偿期患者真菌感染临床特点及危险因素,为临床诊治提供参考。方法选择2007年6月-2014年6月434例肝硬化失代偿期患者,统计其真菌感染率,分析感染分布及真菌特点,对年龄、性别、肝功能分级、消化道出血等潜在因素进行单因素及多因素分析。结果 434例患者真菌感染42例感染率为9.68%,42例感染患者送检标本中有33例培养阳性,分离出35株真菌,以白色假丝酵母菌、热带假丝酵母菌为主分别占37.14%、22.86%;单因素分析结果提示,感染未规范抗病毒治疗、肝功能Child-Pugh分级-C级、消化道出血、重度低蛋白血症、抗菌药物使用>7d、腹膜炎、侵入性操作为感染因素,差异均有统计学意义(P<0.05);肝功能Child-Pugh分级-C、抗菌药物使用>7d、重度低蛋白血症、侵入性操作、消化道出血是真菌感染的独立危险因素(P<0.05)。结论肝硬化失代偿期患者真菌感染率高,危险因素复杂,临床需加强早期干预降低感染率。     

急性百草枯中毒患者急性肾损伤的危险因素分析

目的 分析百草枯中毒患者急性肾损伤(AKI)的病因,探讨影响其预后的危险因素,为早发现、早治疗和改善预后提供帮助。方法 将资料完整的181例患者分为有急性肾损伤组和无急性肾损伤组,采用单因素分析初步筛查出AKI的危险因素,然后将初筛有统计学意义的因素进行Logistic回归分析,判断各因素对AKI的影响。结果 181例急性百草枯中毒患者中50例出现AKI,死亡46例,无急性肾损伤者131例,死亡46例,2组死亡率差异有统计学意义(P<0.001)。Logistic回归分析表明血中性粒细胞计数、血糖、血尿素氮及消化道出血等与百草枯患者发生AKI有较强的相关性(OR值为1.117、1.134、1.477和9.366)。结论 血中性粒细胞计数及血糖升高、发生消化道出血为百草枯中毒患者发生AKI的危险因素。     

肝移植术后患者急性肾损伤危险因素及严重程度分析

目的　分析肝移植术后患者急性肾损伤（acute kidney injury, AKI）的危险因素及AKI严重程度的影响因素。方法　收集2005年1月—2015年8月在我中心进行肝移植手术患者,排除术前AKI患者,共入组469例,对该组患者术前、术中、术后影响AKI的危险因素及术后4周时的转归进行分析、研究。结果　469例患者中,术后发生AKI者274例（AKI组）,无AKI者195例（非AKI组）,发病率为58.4%。受体身体质量指数（body mass index, BMI）、术前肌酐水平、冷缺血时间、手术时间、下腔静脉阻断时间、术后乳酸峰值、术后AST峰值等均是发生AKI的危险因素。术后4周AKI组20.4%患者肾功能仍然异常,病死率为3.6%,较非AKI组明显升高（P=0.027）。结论　肝移植术后发生AKI的影响因素较多,受体BMI、术前肌酐水平、阻断下腔静脉时间、手术时间、术后乳酸峰值、术后AST峰值均是发生AKI的独立危险因素。术后4周AKI组患者肾功能异常及病死率较非AKI组均明显升高。     

农药中毒继发急性肾损伤的危险因素

目的:分析农药中毒患者的临床特征并探讨其发生急性肾损伤（AKI）的危险因素。方法:于2020年9月,回顾性分析西南医科大学附属医院肾病内科2018年9月至2020年8月收治的155例农药中毒患者的临床资料。按照是否发生AKI将患者分为AKI组（44例）和非AKI组（111例）,分析两组患者的临床特征、器官或系统受累情况...     

失代偿期肝硬化患者医院感染危险因素及病原学特点探讨

目的探讨失代偿期肝硬化患者医院感染的病原学特点和危险因素,以期预防和控制医院感染,改善预后。方法选择2010年1月-2016年12月医院收治的失代偿期肝硬化患者682例,采集血液、痰液、咽拭子等标本进行培养,探讨医院感染率及病原学特点,进行失代偿期肝硬化患者医院感染的单因素和多因素分析。结果682例失代偿期肝硬化患者发生医院感染68例,感染率为9.97%,感染部位主要以呼吸道25例为主,占36.76%,腹腔21例占30.89%;感染病原菌主要为革兰阴性菌41株占60.29%,革兰阳性菌17株占25.00%,真菌10株占14.71%,其中革兰阴性菌以大肠埃希菌为主,革兰阳性菌以表皮葡萄球菌为主,真菌均为酵母菌属;多因素logistic研究结果显示:年龄>60岁、住院时间>4周、有侵入性操作、合并并发症、预防使用抗菌药物、肝功能child分级为C级等为失代偿期肝硬化患者医院感染的危险因素(P<0.05)。结论失代偿期肝硬化患者医院感染的危险因素较多,应合理选择抗菌药物,并实行针对性的预防措施。     

影响血管造影术后急性肾损伤的危险因素分析

目的探讨分析影响血管造影术后急性肾损伤的危险因素。方法回顾性分析100例行血管造影术患者的临床资料,依据术后是否发生急性肾损伤分为对比剂肾病(CIN)组和对照组,比较两组的一般临床资料,采用多因素Logistic回归分析血管造影术后急性肾损伤的危险因素。结果100例患者中,22例(22.00%)出现急性肾损伤;两组在年龄、合并症(糖尿病、高血压、高血脂)、术前肌酐水平、术前运用心血管药物及肾功能情况方面具有显著差异(P<0.05);Logistic回归分析结果显示,年龄、合并症、术前运用心血管药物及肾功能不全均是血管造影术后急性肾损伤的危险因素。结论血管造影术后发生急性肾损伤与年龄、合并症、术前运用心血管药物及肾功能不全等均密切相关,临床应进行术前危险性预判并进行针对性防治。     

老年急性肾损伤的治疗转归及危险因素分析

目的探讨影响老年急性肾损伤(AKI)预后的危险因素。方法回顾性分析53例老年AKI患者的临床资料。结果老年AKI的病因方面,感染性疾病占18.9%,慢性肾脏病占18.9%,药物占15.1%,总住院死亡率35.8%。死亡原因败血症占10.6%、感染性休克占26.3%、多器官衰竭占31.6%。结论老年AKI的主要病因为感染性疾病、原有慢性肾脏病和药物。败血症、感染性休克、多器官衰竭、严重酸中毒是老年AKI患者死亡的独立危险因素。     

Prognostic Effect of a Novel Simply Calculated Nutritional Index in Acute Decompensated Heart Failure

The TCB index (triglycerides × total cholesterol × body weight), a novel simply calculated nutritional index based on serum triglycerides (TGs), serum total cholesterol (TC), and body weight (BW), was recently reported to be a useful prognostic indicator in patients with coronary artery disease. Thus, this study aimed to investigate the relationship between TCBI and long-term mortality in acute decompensated heart failure (ADHF) patients. Patients with a diagnosis of ADHF who were consecutively admitted to the cardiac intensive care unit in our institution from 2007 to 2011 were targeted. TCBI was calculated using the formula TG (mg/dL) × TC (mg/dL) × BW (kg)/1000. Patients were divided into two groups according to the median TCBI value. An association between admission TCBI and mortality was assessed using univariable and multivariable Cox proportional hazard analyses. Overall, 417 eligible patients were enrolled, and 94 (22.5%) patients died during a median follow-up period of 2.2 years. The cumulative survival rate with respect to all-cause, cardiovascular, and cancer-related mortalities was worse in patients with low TCBI than in those with high TCBI. In the multivariable analysis, although TCBI was not associated with cardiovascular and cancer mortalities, the association between TCBI and reduced all-cause mortality (hazard ratio: 0.64, 95% confidence interval: 0.44–0.94, p = 0.024) was observed. We computed net reclassification improvement (NRI) when TCBI or Geriatric Nutritional Risk Index (GNRI) was added on established predictors such as hemoglobin, serum sodium level, and both. TCBI improved discrimination for all-cause mortality (NRI: 0.42, p < 0.001; when added on hemoglobin and serum sodium level). GNRI can improve discrimination for cancer mortality (NRI: 0.96, p = 0.002; when added on hemoglobin and serum sodium level). TCBI, a novel and simply calculated nutritional index, can be useful to stratify patients with ADHF who were at risk for worse long-term overall mortality.     

急性失代偿性心力衰竭治疗中的临床用药指导教学体会

目的以左西孟旦用于急性失代偿性心力衰竭(ADHF)的治疗,探讨临床用药指导实习教学的体会。方法以2018年1-12月在该院实习的学生24名作为研究对象,随机分成对照组和观察组,每组12名。对照组选用传统带教方式完成临床教学,观察组采用以左西孟旦治疗ADHF的临床用药指导教学模式,比较两组患者的临床治疗效果、两组实习生的考试成绩及对不同教学模式的满意度。结果观察组学生出科考试成绩明显高于对照组,观察组学生对新教学方式满意度更高,观察组患者心衰症状缓解情况、心功能提高程度明显高于对照组,差异有统计学意义(P<0.05)。结论左西孟旦治疗ADHF的教学中,以临床用药指导教学,既可提高实习生对ADHF相关疾病知识、治疗方法、常用药物及禁忌的掌握程度,还可增强学生交流、沟通的能力,启发探索理论学习与临床实践融合的能力,使学生在新型教学方式下获益更多,教学效果理想。     

Hospital-Acquired Acute Kidney Injury

Abstract

Acute kidney injury (AKI) is a common clinical syndrome in hospitalized patients associated with high morbidity and mortality rates. Despite several years of improvement in the medical care of the severely ill, there has been little improvement in outcome. Furthermore, effective means of preventing and treating AKI have remained elusive. Although dialysis has been the mainstay of treating AKI for > 40 years, several questions regarding its application remain unsettled, including method (continuous vs intermittent), timing, and dose. The purpose of this review is to summarize recent advances in the epidemiology and treatment of AK1 in hospitalized patients.     

Effect of Adding Nitroglycerin to Early Diuretic Therapy on the Morbidity and Mortality of Patients with Chronic Kidney Disease Presenting with Acute Decompensated Heart Failure

Abstract

Background: Loop diuretics are considered first-line therapy for patients with acute decompensated heart failure (ADHF). Adding nitroglycerin (NTG) to diuretic therapy for alleviation of acute shortness of breath has been advocated in our institution. We evaluated the benefits of adding NTG to diuretics in the emergency department for patients with ADHF and chronic kidney disease (CKD). Methods: 430 consecutive patients with ADHF who were admitted with a chief complaint of dyspnea were included in this retrospective study. Patients were divided into 3 groups. Group A patients were treated with neither diuretics nor NTG; Group B patients were treated with diuretics only; and Group C patients were treated with both diuretics and NTG. Estimated glomerular filtration rate (GFR) was calculated according to the Cockcroft-Gault formula. Follow-up was 36 ± 9 (mean ± standard deviation [SD]) months. Primary endpoints were readmission rate at 30 days and mortality at 24 months. Results: 430 patients were included in this study (42% men; age, 69 ± 14 [mean ± SD] years); mean New York Heart Association class was 2.4 ± 0.7 (mean ± SD) and mean ejection fraction was 28% ± 17% (mean ± SD). Group A included 257 (59%) patients, Group B had 127 (29%) patients, and Group C had 46 (11%) patients. Group C patients were older (mean age, 72 ± 13 years) with lower body mass index (26 ± 7 kg/m²), lower estimated GFR (55.8 ± 38 mL/min per 1.73 m²), higher B-type natriuretic peptide levels (1112 ± 876 pg/mL; P = nonsignificant [NS]), and higher systolic and diastolic blood pressures on admission (P = 0.001). The primary endpoint was assessed as a composite of all-cause mortality and ADHF readmission seen in 143 (56%) Group A patients, 68 (53%) Group B patients, and 22 (48%) Group C patients (P = NS). At 30 days there were 53 (12%) readmissions—26 in Group A, 20 in Group B, and 7 in Group C (P = NS). However, survival at 24 months was higher in Group C (87%) compared with Groups A (79%) and B (82%) (P = 0.002). Using the Cox proportional-hazards regression module, early administration of NTG and Lasix (95% confidence interval [CI], 1.06–1.62; P = 0.01) followed by CKD stage (95% CI, 1.00–1.35; P = 0.04) were the only predictors for survival. Conclusion: There is a role for early administration of NTG in addition to diuretic therapy in patients admitted to the emergency department with ADHF, with resultant decreased length of stay and a trend toward a decrease in the composite endpoint of all-cause mortality and ADHF readmission. The mortality benefit at 2 years reported in our study is thought-provoking and raises a premise to be proven in randomized clinical trials.     

Aetiologies and Short-term Outcomes of Acute Kidney Injury in a Tertiary Centre in Southwest Nigeria

Background

Acute kidney injury (AKI) has become a global health problem and is associated with increased morbidity, mortality and overall health expenditure. Information on the epidemiology and outcomes of AKI will help to audit practice and advocate for policies that will reduce this burden. This study determined aetiologies, short term outcomes and their predictors in AKI patients in a tertiary hospital in Southwest Nigeria.

Methods

This was an 18-month retrospective study that involved 91 patients with AKI. The socio-demographic information, aetiology, severity and the treatment given to patients were recorded. Outcomes and their predictors were determined using multivariate analysis. P value < 0.05 was taken as statistically significant.

Results

The mean age of the study population was 45.12 ±20.67 years. Common causes of AKI were sepsis in 50(54.9%), hypovolaemia in 23(25.3%), cardiac failure in 7(7.7%) and eclampsia in 6(6.6%). Fifty-seven (62.6%) presented with stage 3. Thirty-one (34.1%) had haemodialysis. Forty-eight (52.7%) had complete renal recovery, 35(38.5%) died and 3(3.3%) left against medical advice while five (5.5%) were referred to other hospitals. Stage 3 AKI (Adjusted odd ratio: 6.79, confidence interval: 1.21:38.04, p = 0.029) and age ≥ 65 years (Adjusted odd ratio: 4.14, confidence interval: 1.32–13.04, p = 0.015) were significant predictors of mortality in AKI patients.

Conclusion

Sepsis and hypovolaemia were the commonest causes of AKI. The associated mortality is still high and factors associated with mortality were late presentation and older age. Early presentation, treatment and making haemodialysis affordable are key to improving AKI outcomes.     

原发性肾病综合征并发急性肾损伤的相关因素分析

目的探讨原发性肾病综合征（PNS）并发急性肾损伤（AKI）的相关因素,为PNS并发AKI的诊断、预防和治疗提供参考。方法对98例PNS患者的临床资料进行回顾性分析,对PNS并发AKI的相关因素进行分析。结果 PNS并发AKI的发病率为8.16%。单因素分析结果显示,年龄、感染、重度浮肿、24 h尿蛋白、24 h尿量、Hb、Bun/Scr与PNS并发AKI有关（P〈0.05）;而性别、血白蛋白与PNS并发AKI无明显相关性（P〉0.05）。结论 PNS并发AKI的发病率与年龄有关,以老年患者多见;感染是PNS并发AKI的诱因;PNS患者出现重度浮肿,且24 h尿蛋白量显著增加而24 h尿量显著减少,伴有Hb和Bun/Scr水平升高的PNS患者提示可能并发AKI。     

High Plasma Docosahexaenoic Acid Associated to Better Prognoses of Patients with Acute Decompensated Heart Failure with Preserved Ejection Fraction

The clinical relevance of polyunsaturated fatty acids (PUFAs) in heart failure remains unclear. The aim of this study was to investigate the association between PUFA levels and the prognosis of patients with heart failure with preserved ejection fraction (HFpEF). This retrospective study included 140 hospitalized patients with acute decompensated HFpEF (median age 84.0 years, 42.9% men). The patients’ nutritional status was assessed, using the geriatric nutritional risk index (GNRI), and their plasma levels of eicosapentaenoic acid (EPA), docosahexaenoic acid (DHA), arachidonic acid (AA), and dihomo-gamma-linolenic acid (DGLA) were measured before discharge. The primary outcome was all-cause mortality. During a median follow-up of 23.3 months, the primary outcome occurred in 37 patients (26.4%). A Kaplan–Meier analysis showed that lower DHA and DGLA levels, but not EPA or AA levels, were significantly associated with an increase in all-cause death (log-rank; p < 0.001 and p = 0.040, respectively). A multivariate Cox regression analysis also revealed that DHA levels were significantly associated with the incidence of all-cause death (HR: 0.16, 95% CI: 0.06–0.44, p = 0.001), independent of the GNRI. Our results suggest that low plasma DHA levels may be a useful predictor of all-cause mortality and potential therapeutic target in patients with acute decompensated HFpEF.     

肺部感染患者住院期间发生急性左心力衰竭的危险因素分析

目的探讨肺部感染患者住院期间发生急性左心力衰竭的危险因素,并采取相应的干预措施。方法回顾性分析2014年1月至2019年3月期间我院200例肺部感染住院患者的临床资料,根据患者住院期间是否发生急性左心力衰竭将其分为心衰组(35例)和非心衰组(165例),对肺部感染患者住院期间发生急性左心力衰竭因素进行单因素和多因素Logistic回归分析。结果200例肺部感染患者的血培养致病菌阳性率为30.5%(61例),以革兰氏阴性菌和革兰氏阳性菌为主。单因素分析显示,急性左心力衰竭发作与年龄、pro-BNP水平、心脏增大证据、高血压、心衰发作史或AMI史均有相关性(P<0.05),而与性别、糖尿病史、肾功能不全、联用抗生素、补液量无相关性(P>0.05)。Logicstics回归分析显示,年龄、补液速度、高血压、心衰发作史或AMI史是肺部感染患者发生急性左心力衰竭的相关危险因素(P<0.05)。监测pro-BNP水平,控制血压,对高龄、有心衰发作史或AMI史的患者注意利尿,控制补液速度,予以调节神经体液因素口服药为防止急性左心力衰竭发作的保护因素。结论肺部感染患者发生急性左心力衰竭的危险因素较多,主要为年龄、高血压、心衰发作史或AMI史、补液速度,临床上应采取相应措施预防肺部感染患者在住院期间发生急性左心力衰竭。     

通阳活血汤治疗心肾阳虚型心衰的临床分析

目的评价通阳活血汤治疗心肾阳虚型慢性心力衰竭患者的疗效。方法 90例心肾阳虚型慢性心力衰竭患者,分成观察组和对照组。对照组:西医常规治疗;观察组:在对照组治疗方式上,加用通阳活血汤。结果观察组总有效率95.56%(43/45)高于对照组总有效率80.00%(36/45),具有显著性差异(P<0.05)。两组90例患者均未发现明显不良反应。结论通阳活血汤治疗心肾阳虚型慢性心力衰竭患者疗效可靠,安全性高,具有重要的临床意义。     

急性肾损伤患者手术后住院死亡率和肾替代治疗启动时机之间的关系

目的观察手术后急性肾损伤（AKI）患者肾替代性治疗（renal replacement therapy,RRT）时机与住院死亡率的关系,并就护理措施进行探讨。方法回顾性分析河南鹤壁煤业公司总医院2005-01/20012-12泌尿科手术后AKI患者进行RRT治疗的资料,采集人口学资料、伴发疾病、手术和RRT种类、RRT的指征。根据入住ICU～RRT启动时间分为早期（≤1 d）、中期（2～3 d）、后期（≥4 d）组,住院死亡率以120 d作为终点。结果 660例中患者中382例（57.8%）住院期间死亡。根据Cox比例风险方法,后期组与中期组比较,比例风险为1.525,95%置信区间为1.152～2.023（P〈0.01）、年龄（1.014;1.006～1.021）、糖尿病（1.279;1.022～1.601;P〈0.05）、肝硬化（2.147;1.421～3.242）、体外氧支持治疗（1.811;1.391～2.359）、神经功能障碍（1.448;1.107～1.894;P〈0.01）、RRT前平均动脉血压（0.988;0.981～0.995）、变力性药物（1.006;1.001～1.012;P〈0.01）、APACHE II评分（1.055;1.037～1.073）、脓毒症（1.939;1.536～2.449）是住院死亡率的独立预测因素。结论本研究结果显示,入住ICU后启动RRT时机与患者住院死亡率之间存在关联,糖尿病、肝硬化等疾病对RRT预后有严重影响。