CCU患者发生急性肾损伤的现状调查及中医证候研究

目的调查中医院冠心病重症监护室(CCU)患者急性肾损伤(AKI)的发生情况及中医证候特点。 方法回顾性研究北京中医药大学东直门医院2015年1月1日到2015年12月31日入住CCU的患者,采用KDIGO指南推荐的AKI诊断标准,将患者分为AKI组和非AKI组,比较两组的人口学资料及临床特征、治疗、转归、中医证候特点,并用多因素Logistic回归分析AKI发生的危险因素。 结果共纳入186例患者,发生AKI 65例(35.0%),漏诊率为89.2%。①人口学资料及临床基本特征：年龄、发生多脏器功能衰竭、尿素氮、血肌酐(Scr)在AKI组明显高于非AKI组(P<0.001);N末端脑钠肽(NT-BNP)升高、双下肢水肿、合并高血压、高尿酸血症在AKI组高于非AKI组(P<0.05);②治疗：利尿剂在AKI组的使用明显高于非AKI组(χ²＝17.729,P<0.001); ③多因素Logistic回归分析显示使用利尿剂(OR＝6.980,CI 2.287～21.306)、eGFR<90 ml/(min·1.73 m²)(OR＝2.201,CI 1.076～4.504)、发生非肾多脏器功能衰竭(OR＝3.733,CI 1.602～8.702)是AKI发生的独立危险因素;④转归：院内死亡在AKI组明显高于非AKI组(χ²＝16.510,P<0.001)、出院Scr在AKI组明显高于非AKI组(Z＝－7.683,P<0.001);⑤中医证候：水停证在AKI组高于非AKI组(χ²＝0.024,P<0.05);在虚证中,气虚出现频率最高、其次为阴虚;在实证中,血瘀出现频率最高、其次为痰证;AKI患者虚实夹杂所占比例最高(50.8%)。 结论中医院CCU患者AKI的发生存在着高发病率、高漏诊率的特点。临床治疗中应谨慎使用大剂量利尿剂、注重肾脏及其它重要脏器的保护。中医治疗应注重"心肾同治"及"标本兼顾",以益气养阴,活血化瘀为主,兼用利水化痰。

Investigation on the status quo of acute kidney injury incidence in CCU patients and TCM syndromes analysis

ObjectiveTo investigate the incidence of acute kidney injury (AKI) in the coronary care unit (CCU) of the hospital of Chinese medicine and the characteristics of traditional Chinese medicine (TCM) syndromes. MethodsA retrospective clinical study was performed in the patients admitted into the CCU of Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine from January 1, 2015 to December 31, 2015. The patients were divided into AKI group and non-AKI group according to the diagnosis criteria of AKI recommended by KDIGO guidelines. The two groups were compared in demographic data, clinical features, treatment, clinical outcome, and TCM symptoms. Multivariate logistic regression method was used to analyze risk factors of AKI. ResultsTotal 186 cases were enrolled in this study, including 65 cases (34.5%) of AKI, and the rate of missed diagnosis was 89.2%. ①Demographic data and clinical features: The ages, multiple organ failure incidences, and levels of urea nitrogen and serum creatinine (Scr) were significantly higher in the AKI group than in the non-AKI group (P<0.001); The incidences of N-terminal pro-B-type natriuretic peptide (NT-BNP) increase, lower extremity edema, hypertension, and hyperuricemia were higher in the AKI group than in the non-AKI group (P<0.05). ②Treatment: The incidence of diuretics use was significantly higher in the AKI group than in the non-AKI group (χ²=17.729, P<0.001). ③Multivariate logistic regression analysis showed that the diuretics use (OR=6.980, CI 2.287-21.306), eGFR <90 ml/(min·1.73 m²) (OR=2.201, CI 1.076-4.504), and non-renal multiple organ failure (OR=3.733, CI 1.602-8.702) were the independent risk factors of AKI. ④Clinical outcomes: In the AKI group, both the hospital mortality rate (χ²=16.510, P<0.001) and the Scr at discharge (Z=-7.683, P<0.001) were significantly higher than those in the non-AKI group. ⑤TCM syndromes: The incidence of water stagnation syndrome was higher in the AKI group than in the non-AKI group (χ²=0.024, P<0.05). Among the deficiency syndromes, the incidence of Qi deficiency syndrome was the highest, while the incidence of Yin deficiency syndrome the second highest. Among the excess syndromes, the incidence of blood stagnation syndrome was the highest, and the incidence of phlegm syndrome the second highest. The incidence of intermingled deficiency and excess (50.8%) was the highest among all syndromes in the AKI group. ConclusionsThe occurrence of AKI in the CCU of the hospital of Chinese medicine was featured with high incidence rate and high missed diagnosis rate. In clinical treatment, high-dose diuretics should be used with caution, emphasizing on the protection of kidneys and other vital organs. For TCM therapy, attention should be paid to "simultaneous treatment of heart and kidney" for "both symptoms and root causes" , with a focus on tonifying the Qi and nourishing the Yin, and activating the blood and dissolving the stasis, as well as excreting the water and eliminating the phlegm.