各评分系统对胰腺炎疾病严重程度预测价值的临床研究

目的：探讨各评分系统对急性胰腺炎（acute pancreatitis,AP）疾病严重程度预测价值的差异。方法回顾性分析156例 AP 患者的临床资料,记录患者入院时的 c-反应蛋白（CRP）等实验室检测值,结合中国胰腺炎诊治指南（2007）将患者分为轻症胰腺炎（mild acute pancreatitis, MAP）组、重症胰腺炎（severe acute pancreatitis,SAP）组。按照各评分系统的相应评分标准对患者进行急性生理学和慢性健康状况评分（APACHEⅡ）、Ranson、BISAP、CTSI 评分。按照APACHEⅡ≥8分、Ranson≥3分、BISAP≥2分、CTSI≥3分、CRP≥21．4 mg／L 的标准分别将患者区分为 MAP 组、SAP 组,ROC 曲线比较各评分系统对 AP 疾病严重程度预测价值的差异。结果156例 AP 患者,确诊为 SAP21例,另135例诊断为 MAP。APACHEⅡ≥8分、Ranson≥3分、BISAP≥2分、CTSI≥3分、CRP≥21．4 mg／L 预测 SAP 的 AUC 分别为0．78（95％CI：0．70～0．84）,0．69（95％CI：0．62～0．76）,0．74（95％CI：0．66～0．80）,0．69（95％ CI：0．61～0．76）,0．68（95％CI：0．57～0．78）,各评分系统间差异无统计学意义。结论各评分系统对 SAP 的预测价值差异无统计学意义,在临床工作中,SAP 的早期预测应参考多种评价体系,临床获取及应用更为简便的单一实验室指标的参考意义,值得进一步深入研究。     

An improvement in the outcome of acute renal failure

BACKGROUND: Acute renal failure (ARF) requiring hemodialysis (HD) treatment is related to high mortality. The aim of this study was to analyze the influence of age, disease severity, and catabolism intensity on ARF outcome in patients requiring HD treatment during a 15-year period (1987-2001). METHODS: The retrospective, single-center study included 583 patients, 428 male, 155 female, age 49+/-15 years, treated by intermittent HD using cuprophane membranes with surface area of 1.3 m2. Liano's Acute Tubular Necrosis Individual Severity Score (ATNISS) score and Hypercatabolism Depuration Score (HDS) score were calculated to estimate disease severity and catabolism intensity in ARF patients. RESULTS: Average age of patients significantly increased during the 15-year period for more than one decade (44 to 55 years; p=0.0359), especially during the last five-year period (47+/-14.5 vs. 53+/-14.7, p=0.00015). Disease severity showed significant increase comparing periods 1992-1996 and 1997-2001 (ATNISS 0.385+/-0.197 vs. 0.437+/-0.208; p=0.00137), while catabolism intensity during these periods was similar (HDS 0.569+/-0.145 vs. 0.582+/-0.127; p=0.357). Despite the older and more severely ill population of ARF patients, mortality showed a sustained decrease during the 15-year period. Mortality in the period from 1987 to 1991 (49/83; 59%) was similar with the period 1992-1996 (chi2=0.44, p=0.5081), but significantly higher than in the period 1997-2001 (114/250; 45.6%; chi2=3.98, p = 0.0471). CONCLUSION: The results showed an improvement in the outcome of patients with ARF requiring HD treatment, despite increasing age, disease severity, and use of bioincompatible membranes.     

Exercise-induced acute renal failure in a patient with renal hypouricemia

We describe a case of exercise-induced acute renal failure (ARF) in a patient with hypouricemia. Following recovery from ARF, the patient’s serum urate concentration was 0.6–0.9 mg/dl, and the ratio of urate clearance to creatinine clearance (C _ua/C _Cr) was 41.9%–56.6%. There was no change in the C _ua/C _Cr following the administration of pyrazinamide or probenecid, suggesting defects of tubular urate/anion exchangers. Because the renal biopsy revealed acute tubular necrosis without uric acid crystals, the ARF of this patient might be due to oxygen free radicals resulting from exercise stress and hypouricemia. Received: 15 March 1999 / Revised: 10 September 1999 / Accepted: 14 September 1999     

Severity of illness scoring systems and performance appraisal

A large number of severity of illness scoring systems have been developed and they are widely used in intensive care practice. However, they are complex systems with their basis in mathematics. To use such systems effectively, it is important to appreciate what factors influence their performance so that they can be compared fairly and used most appropriately. The purpose of this review is to describe the methods commonly used to assess the various facets of performance in severity of illness scoring systems. The performance of the most frequently used scoring systems in adult intensive care practice are presented. The shortfalls, misuse and strengths of scoring systems are also discussed.     

Comparison of patient outcome according to renal replacement modality after renal allograft failure

The aim of this study is to investigate the clinical course of patients with failed allograft according to the type of renal replacement modality. Three hundred sixty-eight patients with failed allograft were included. Of these, 233 patients started hemodialysis (HD-PSKT), 64 patients started peritoneal dialysis (PD-PSKT), and 71 patients underwent second transplantation (ReKT). At baseline, age, sex, laboratory findings, and comorbidity did not differ significantly among three groups. Chronic rejection was the most common cause of allograft failure (81.6%) followed by acute rejection (10.7%). During the observation period, 96 patients died. The most common cause of death was cardiovascular disease (39.6%) followed by infection (34.4%) and malignancy (8.3%). Infection was important cause of death within 10 years from allograft failure, but cardiovascular disease and malignancy occupied significant portion of death after 10 years from allograft failure. Significant difference was not found among the three groups in the cause of allograft failure and the cause of death. The patient outcome was better in the ReKT than in the other two groups and it did not differ significantly between the PD-PSKT and HD-PSKT. In multivariate analysis, old age, hypoalbuminemia, and high comorbidity were proved to be the independent risk factors for mortality and the ReKT was still significantly superior to the HD-PSKT and PD-PSKT after adjustment for other confounding factors. In conclusion, second transplantation may result in survival benefit, and proper management of nutrition and comorbidity may help to improve outcome in patients with failed allograft.     

不同肾结石评分系统在经皮肾镜取石术中的应用价值研究

目的 探讨Guy's分级系统、S.T.O.N.E.评分系统及SHA.LIN评分系统在经皮肾镜取石术（PCNL）中的应用价值。方法 回顾性分析哈密红星医院2016年6月至2018年5月间行PCNL治疗的142例肾结石患者的临床资料,按照Guy's分级系统、S.T.O.N.E.评分系统及SHA.LIN评分系统分别对患者的术前结石特征进行量化分级和评分,分析并比较三种评分系统与结石清除率、围手术期并发症及手术时间等因素之间的关系。结果 患者结石清除率为66.9% (95/142),43例(30.3%)出现围手术期并发症。三种评分系统与术后结石清除率、术中出血量及手术时间均具有相关性（P<0.05）,仅SHA.LIN评分系统与预测出血量有相关性（P=0.023）。Guy's分级系统、S.T.O.N.E.评分系统及SHA.LIN评分系统的受试者工作特征曲线的曲线下面积分别为0.742、0.828、0.894。结论 三种肾结石评分系统均具有完善病情评估的能力,三种评分系统与术后结石清除率、术中出血量及手术时间均具有相关性,而SHA.LIN评分系统在预测出血量方面优于Guy's分级系统和S.T.O.N.E.评分系统。     

Influence of renal replacement therapy on outcome of patients with acute renal failure

There are many controversial results about the influence of acute renal failure (ARF) and renal replacement therapy (RRT) on patient outcome in intensive care units. This retrospective study compared demographics. severity, course, and prognosis of ARF during 36 months (period 1, 1991 through 1993; 128 cases) and 18 months (period 2, 1994 through 1995; 141 cases). Compared with period 1, during period 2 there was a markedly increased incidence of ARF. There were no significant differences in patient demographics or etiology of renal failure, but the therapeutic approach to ARF was quite different. During period 2, RRT was started at earlier stages of renal insufficiency (that is, less elevated creatinine serum concentrations or reduced diuresis). Additionally, there was a significant increase in the numbers of continuous RRT (CRRT) replacing the discontinuous mode of dialysis treatment. Compared with period 1, mortality was reduced from 78.9 to 59.6% during period 2 (P < 0.001). There were no differences in mortality between the patients from internal and surgical wards. Mortality in patients treated with CRRT was in period 1 and in period 2 higher than mortality in patients treated with intermittent RRT, but these results are biased by a preferred use of CRRT in severely ill patients with an unstable circulatory system. These data suggest that the early onset of RRT reduces the mortality of intensive care unit patients with ARF independent of underlying diseases. An influence of the method of RRT, sex, and age on outcome of patients with ARF could not be proven.     

Predicting outcome from closed head injury by early assessment of trauma severity

The relationship between severity of head injury and outcome was studied in 96 patients. Severity was assessed based on the level of coma and presence of mass lesion, hemiparesis, skull fracture, and pupil abnormality. Outcome was assessed using the Wechsler Adult Intelligence Scale, the Halstead-Reitan neuropsychological battery, and the Glasgow Outcome Scale. The relationship between assessment of severity of trauma and the outcome measurements was calculated by multiple regression analysis. Results indicate that coma grade and estimates of premorbid intelligence quotient (IQ) served best to predict IQ as assessed after the injury. The combination of coma grade, mass lesion, and skull fracture were important predictors of the Halstead Impairment Index. Coma grade and pupil abnormality predicted the Glasgow Outcome Scale. Low to moderate relationships were found between the predictor variables and the measurement of IQ and the Glasgow Outcome Scale; multiple regression coefficients were 0.63 and 0.61, respectively. The relationship between measurement of trauma severity and the Halstead Impairment Index was also low (R = 0.37).     

Comparison of the severity of illness scoring systems for critically ill cirrhotic patients with renal failure

BACKGROUND: Mortality rates of cirrhotic patients with renal failure admitted to the medical intensive care unit (ICU) are high. End-stage liver disease is frequently complicated by disturbances of renal function. This investigation is aimed to compare the predicting ability of acute physiology, age, chronic health evaluation II and III (APACHE II and III), sequential organ failure assessment (SOFA), and Child-Pugh scoring systems, obtained on the first day of ICU admission, for hospital mortality in critically ill cirrhotic patients with renal failure. METHODS: Sixty-seven patients with liver cirrhosis and renal failure were admitted to ICU from April 2001-March 2002. Information considered necessary for computing the Child-Pugh, SOFA, APACHE II and APACHE III score on the first day of ICU admission was prospectively collected. RESULTS: The overall hospital mortality rate was 86.6%. Liver disease was most commonly attributed to hepatitis B viral infection. The development of renal failure was associated with a history of gastrointestinal bleeding. Goodness-of-fit was good for SOFA, APACHE II and APACHE III scores. The APACHE III and SOFA models reported good areas under receiver operating characteristic curve (0.878 +/- 0.050 and 0.868 +/- 0.051, respectively). CONCLUSION: Renal failure is common in critically ill patients with cirrhosis. The prognosis for cirrhotic patients with renal failure is poor. APACHE III and SOFA showed excellent discrimination power in this group of patients. They are superior to APACHE II and Child-Pugh scores in this homogenous group of patients.     

Mortality risk factors and validation of severity scoring systems in critically ill patients with acute renal failure

BACKGROUND: Risk stratification and prediction of outcome in acute renal failure patients in the intensive care unit are important determinants for improvement of patient care and design of clinical trials. METHODS: In order to identify mortality risks factors and validate general and specific predictive models for acute renal failure (ARF) patients in the intensive care unit (ICU), 324 patients were prospectively evaluated. Multivariate analysis by logistic regression was utilized for identification of mortality risk factors. Discrimination and calibration were used to evaluate the performance of the following models at referral to nephrologist and at initiation of renal replacement therapy: APACHE II, SAPS II, LODS, and ATN-ISI. Organ failure was assessed by SOFA and OSF. RESULTS: The hospital mortality rate was 85%. The identified mortality risk factors were: age > or = 65 yr, BUN > or = 70 mg/dL, ARF of septic origin, and previous hypertension. Serum creatinine > or = 3.5 mg/dL, systolic blood pressure > or = 100 mm Hg, and normal consciousness were associated with mortality risk reduction. Performance of all prognostic models was disappointing with unsatisfactory calibration and underestimation of mortality on the day of referral to the nephrologist and at initiation of renal replacement therapy. CONCLUSIONS: Cross-validation of prognostic models for ARF resulted in poor performance of all studied scores. Therefore, a specific model is still warranted for the design of clinical trials, comparison of studies, and for prediction of outcome in ARF patients, especially in the ICU.     

Severity of illness scoring systems

Data collection on the ICU is necessary to facilitate research, quality assurance and resource management. Severity of illness scoring systems aid the case-mix adjusted collection of such data. However, none is perfect and their use to triage individual patients or to compare the quality of care in different ICUs is severely limited. An appreciation of their limitations and the statistical methods of assessing their goodness of fit are vital if the information that they provide is to be used appropriately.Potential uses for scoring systems include:

• •case-mix adjustment for entry into randomized controlled trials
• •audit and comparison of ICU performance
• •a mechanism to decide resource allocation.

Scoring systems use a logistic regression equation based, variably, on disease severity, age and diagnosis to derive the probability of hospital death (on a scale of 0 to 1, where 0 = survival and 1 = death). The standardized mortality ratio (SMR) describes the ratio of expected to observed deaths. Case-mix variation and the need to derive binary (live or die) data from a probability estimate, limit the use of such systems to evaluate ICU performance.     

Prediction of outcome in acute renal failure

In an attempt to predict outcome in acute renal failure (ARF) we have utilized multiple logistic regression to analyze clinical data from 151 patients with ARF seen over a 15-month period. Recovery of renal function occurred in 60% of patients with a 58% survival. Our analysis demonstrated sepsis, respiratory failure, and oliguria to be the major predictors of nonrecovery of renal function. A logistic equation was generated for prediction of outcome and was validated in a second independent group of patients with ARF. Prediction of outcome could be achieved with a sensitivity of 75% and a specificity of 80%. Maximum sensitivity (100%) was associated with a 17% specificity, while maximum specificity (98%) yielded a sensitivity of 20%.     

Systems for scoring severity of illness in intensive care

Severity of illness scoring systems are increasingly being used by many intensive care units to predict mortality and to compare results and different therapies. A study was undertaken to evaluate three of these systems--therapeutic intervention scoring system (TISS), acute physiology and chronic health evaluation (APACHE II), and organ failure--in a 2-year prospective analysis in a multidisciplinary intensive care unit. A total of 728 patients with a wide variety of diseases were entered into the study. The relationship between score and mortality in all patients and in specific groups was investigated. The APACHE II system is likely to be the most useful in comparing different therapies and intensive care units, while the organ failure system was more accurate in predicting outcome. No system was precise enough in its predictive powers to make decisions to deny or terminate treatment.     

Alterations of thyroid hormone indices in acute renal failure and in acute critical illness with and without acute renal failure

The present study evaluated thyroid hormone indices of patients with acute renal failure without other systemic illnesses (n = 12), as compared to patients with critical illnesses in the presence (n = 16) and absence (n = 6) of acute renal failure. Abnormalities in the group with acute renal failure alone included decreased serum levels of total T4 and T3, and elevated levels of free rT3. Serum levels of free T4 by equilibrium dialysis and the enzyme immunoassay, T3 uptake ratios, TSH and total rT3 were normal. These findings are consistent with the presence of decreased binding of T4 and rT3 to their serum carrier proteins. Critically ill patients with acute renal failure differed in that they had lower total T4 and T3 levels and elevated T3 uptake ratio values. As in the group with acute renal failure alone, total rT3 levels were normal and free rT3 values were elevated. The group with critical illness alone differed only in that the total rT3 concentrations were elevated in all patients. The alterations of thyroid hormone indices in acute renal failure are similar to those of other nonthyroidal illnesses with the exception of the normal total rT3 levels. This suggests that the failing kidney or the metabolic consequences of uremia specifically affect rT3 metabolism.     

Comparison of three Glasgow multifactor prognostic scoring systems in acute pancreatitis

Modifications have been proposed in an attempt to improve the clinical value of the original nine-factor Glasgow prognostic scoring system for acute pancreatitis. These include the omission of age or serum transaminase, reducing the factors to eight. Debate exists as to which system should be employed. Assessment of the individual factors in 198 attacks of acute pancreatitis treated conventionally revealed that only serum transaminase did not differ significantly between mild and severe outcome groups. Multivariate analysis demonstrated four factors (Pa,O2, white cell count, lactic dehydrogenase, and urea) with independent significance in predicting severity, while serum glucose, albumin and transaminase were least useful. Findings were similar when considering only patients with gallstone aetiology. The reduction of the prognostic factors to eight by the omission of either age or transaminase improved the predictive value of the scoring system, both when considering all attacks and those of gallstone aetiology alone. We suggest that serum transaminase should be omitted because: it shows no significant difference between mild and severe outcome groups, while age has prognostic significance; the system has greater sensitivity than if age is omitted; and the number of factors requiring emergency laboratory measurement for immediate prognostication is reduced by one.