老年脓毒症并发急性肾损伤患者持续肾脏替代治疗启动时液体过负荷与预后的相关性

目的探讨老年脓毒症并发急性肾损伤（acute kidney injury, AKI）患者在持续肾脏替代治疗（continuous renal replacement therapy, CRRT）启动时液体过负荷（fluid overload, FO）与预后的关系。 方法选取2015年6月至2018年12月浙江医院重症医学科收治的接受CRRT的65岁以上老年脓毒症并发AKI患者68例，收集患者入ICU后诊断为脓毒症时的基线资料，CRRT启动时的AKI分期、血生化指标、序贯器官衰竭评分（sequential organ failure assessment, SOFA）评分、前一日尿量，入ICU后诊断为脓毒症到CRRT启动时的液体进出量、间隔时间以及利尿剂、血管活性药物应用等情况。主要结局为CRRT启动后28 d死亡。比较CRRT启动后28 d生存患者与死亡组患者的基线资料、CRRT启动时的临床资料，以及不同液体容量状态患者的临床资料并作生存曲线分析，将单因素分析（采用秩和检验、t检验及χ²检验）有统计学意义的指标纳入多因素Logistic回归模型，分析CRRT启动后28 d死亡的相关因素。 结果68例患者在CRRT启动后28 d时存活22例（生存组），死亡46例（死亡组）；两组患者基线资料中仅年龄、平均动脉压的差异有统计学意义（Z=1.991，t=2.491；P<0.05）；CRRT启动时，两组患者SOFA、前一日尿量、每日去甲肾上腺素用量、液体正平衡量、FO>10%患者比例的差异均有统计学意义（t=0.879，Z=2.343、2.042、2.222、2.229，χ²=6.852；P<0.05）。CRRT启动时，FO>10%与FO≤10%的两组患者，仅年龄、血尿素氮、间隔时间、液体正平衡量的差异有统计学意义（Z=4.110、2.079、6.101、6.964，P<0.05）；FO>10%的患者在CRRT启动后28 d的死亡率显著高于FO≤10%的患者（83.8%、54.1%，χ²=6.852，P<0.01）。将年龄、基线平均动脉压、CRRT启动前一日尿量、CRRT启动时的SOFA及血尿素氮、每日去甲肾上腺素用量、液体正平衡量、诊断为脓毒症到CRRT启动时的间隔时间、FO>10%的患者比例纳入多因素logistic回归模型，结果显示CRRT启动时的SOFA以及FO>10%是CRRT启动后28 d死亡的独立相关因素（OR=1.354、16.140，95%CI=1.069-1.715、1.883-138.379，P<0.05）。 结论老年脓毒症并发AKI患者在CRRT启动时FO>10%是28 d死亡的独立危险因素，在液体负荷持续加重时应尽早启动CRRT。

Correlation between fluid overload and prognosis in elderly patients with sepsis complicated with acute kidney injury at initiation of continuous renal replacement therapy

ObjectiveTo investigate the relationship between fluid overload and prognosis in elderly patients with sepsis complicated with acute kidney injury (AKI) during the initiation of continuous renal replacement therapy (CRRT). MethodsEnrolled 68 elderly patients with sepsis-induced AKI receiving CRRT who were admitted to Zhejiang Hospital from June 2015 to December 2018. The clinical data collected included baseline data at the time of ICU admission for sepsis diagnosis; AKI staging, laboratory data, sequential organ failure assessment (SOFA) score at the beginning of CRRT, and urine output of the previous day; amount of fluid balance, time elapsed, and use of diuretics and vasopressors from sepsis diagnosis to CRRT initiation. The primary outcome was 28-day death after CRRT initiation. Compared the data at the baseline and at the initiation of CRRT of the survival group and the death group. Compared the data of patients with different fluid volume status and performed Kaplan-Meier survival curve analysis. The indexes with statistical significance in univariate analysis (rank sum test, t test and chi square test) were included in the multivariate logistic regression model to analyze the related factors of death 28 days after CRRT. ResultsAmong 68 patients, 22 survived 28 days after CRRT initiation (survival group) and 46 died (death group). There were significant differences in age and mean arterial pressure between the two groups (Z=1.991, t=2.491; P < 0.05). At the start of CRRT, there were significant differences in SOFA, urine volume of the previous day, norepinephrine level, positive fluid balance, and FO > 10% of patients between the two groups (t=0.879, Z=2.343, 2.042, 2.222, 2.229, χ²=6.852; P < 0.05); and there were significant differences in age, blood urea nitrogen, interval time, and positive fluid balance between the two groups with FO > 10% and FO≤10% (Z=4.110, 2.079, 6.101, 6.964, P < 0.05). The mortality of patients with FO > 10% was significantly higher than that of patients with FO≤10% (83.9% vs 54.1%, χ²=6.852; P < 0.01). Logistic regression analysis showed that SOFA at CRRT and FO > 10% were independent related factors for death at 28 d after CRRT (OR=1.354, 16.140; 95%CI=1.069-1.715, 1.883-138.379; P < 0.05). ConclusionIn elderly patients with sepsis induced AKI, FO > 10% at CRRT initiation is an independent risk factor for 28-day death, CRRT should be initiated as soon as the fluid load continues to increase.