不同感染部位脓毒症急性肾损伤发生率及相关死亡风险分析

金魁; 王玉兰; 汪跃国; 朱云峰; 李雪芳; 朱家善; 周树生; 徐军

doi:10.13201/j.issn.1009-5918.2021.07.002

不同感染部位脓毒症急性肾损伤发生率及相关死亡风险分析

- 1. 中国科学技术大学附属第一医院急救中心急诊重症医学科(合肥, 236000);
- 2. 中国医学科学院北京协和医院急诊科
基金项目:
中央高校基本科研业务费专项资金,中国科学技术大学联合基金培育项目(No:WK9110000196)

北京协和医学基金-睿E(睿意)急诊医学科研专项基金(No:R2020001)

详细信息

通讯作者: 徐军,E-mail:xujunfree@126.com

中图分类号: R631.2

收稿日期: 2021-05-17

Risk factors and outcomes of acute kidney injury among septic patients with different infection sites

- 1. Department of Emergency Critical Care Medicine, the First Affiliated Hospital of University of Science and Technology of China, Hefei, 236000, China;
- 2. Department of Emergency, Peking Union Medical College Hospital, Chinese Academy of Medical Sciences

More Information

Corresponding author: XU Jun, E-mail: xujunfree@126.com

Received Date: 17 May 2021

摘要

摘要: 目的:探讨危重患者中不同感染部位对脓毒症相关急性肾损伤(SAKI)发病率及相关死亡率的影响,并分析不同感染部位SAKI发生的相关危险因素。方法:回顾性队列研究,选择2018年1月—2020年12月期间收住中国科学技术大学附属第一医院重症医学科的脓毒症患者,根据患者感染部位的诊断将患者分组(肺部感染、血流感染、腹腔感染和泌尿系感染),比较各组患者7 d内的AKI发病率和30 d相关死亡风险,同时分析不同感染部位中重度AKI(AKI 2~3级)发生的相关危险因素。评价不同感染部位对患者SAKI发病率的影响。结果:纳入患者1489例,其中肺部感染患者643例(43.2%),血流感染366例(24.6%),腹腔感染317例(21.3%),泌尿系感染患者162例(10.9%)。发生AKI 2~3级的患者260例(17.6%),其中腹腔感染组AKI 2~3级的发生率最高(25.2%),其次为泌尿系感染(20.4%),后为肺部感染(15.1%)和血流感染(15.0%)。本研究中30 d患者总体死亡率为22.6%,COX多因素回归提示AKI是患者死亡的独立危险因素(HR=2.97,95%CI:1.67~4.27,P=0.023),肺部感染患者AKI相关死亡风险最高(HR=4.47,95%CI:2.15~6.78,P=0.032),其后为腹腔感染(HR=3.32,95%CI:1.78~4.59,P<0.001)、血流感染(HR=2.71,95%CI:1.24~4.18,P=0.013)和泌尿系感染(HR=1.38,95%CI:1.03~1.77,P=0.043)。多因素logistic回归提示入院时APACHEⅡ评分、肌酐水平、乳酸水平、使用血管活性药物、液体超负荷是不同感染部位患者罹患AKI共同的危险因素。早期液体复苏是4组患者发生AKI的保护因素。此外,使用万古霉素是肺部感染和腹腔感染AKI发生的独立危险因素,肝脏损伤是腹腔感染AKI发生的独立危险因素,低血钠是泌尿系感染中AKI发生的保护因素。结论:在不同感染部位的患者中发生AKI均较为常见,显著影响患者死亡率,不同感染部位的患者相关死亡风险有所不同,导致AKI发生的危险因素也不完全相同,提示未来的研究或应当针对不同感染部位制定脓毒症和SAKI诊治的个体化方案。
- 急性肾损伤 /
- 感染部位 /
- 脓毒症 /
- 死亡率
Abstract: Objective: To evaluate the incidence of acute kidney injury among critically ill patients with different sites of infection, the clinical outcome, as well as risk factors associated with the development of AKI, was also analyzed in this study.Methods: A retrospective cohort study was performed. Patients with sepsis admitted to the Department of Intensive Care Medicine of the First Affiliated Hospital of University of Science and Technology of China between January 2018 and December 2020 were enrolled. These patients were stratified into four cohorts depending on the site of infection(pulmonary, bloodstream, abdominal infection, and urinary). Patients' data and culture results were retrieved from the hospital's electronic database. The development of AKI, as well as 30-day mortality, were determined among groups using multi-logistic and COX regression model.Results: A total of 1489 patients were finally enrolled in this study, among them, 643(43.2%) were judged as pulmonary infection, 366(24.6%) were bloodstream infection, 317(21.3%) were abdominal infection, and 162(10.9%) were urinary infection. Generally, 260(17.6%) patients developed moderate to severe acute kidney injury(AKI stage 2-3), the incidence of AKI stage 2-3 was most seen in abdominal infection 25.2%, followed by urinary infection(20.4%), pulmonary infection(15.1%), and bloodstream infection(15.0%). The mortality for all enrolled patients was 22.6%, COX regression model indicate that AKI was an independent risk factor associated with mortality(HR=2.97, 95%CI: 1.67-4.27, P=0.023), with pulmonary infection had the highest hazard ratio, followed by abdominal infection, blood flow infection, and urinary infection. Multivariable logistic regression showed that APACHE Ⅱ score, serum creatinine, lactate concentration, use of vasopressors, and fluid overload were independent risk factors associated with the occurrence of AKI. Early fluid resuscitation was the protective factor of AKI. In addition, the use of vancomycin was an independent risk factor associated with the occurrence of AKI only among pulmonary and abdominal infection patients. The elevated liver enzyme was independent risk factor in abdominal infection, and lower natrium level was associated with decreased occurrence of AKI among urinary infection patients.Conclusion: AKI was common among patients with sepsis of all different infection sites, which significantly increase the risk of death. Risk of death as well as factors associated with occurrence of AKI in patients with different infection sites may not the same. Suggesting that future research may need to focus on individualized treatment for sepsis and sepsis-associated acute kidney injury.
- acute kidney injury /
- infection site /
- sepsis /
- mortality

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参考文献(34)

[1]	Peerapornratana S,Priyanka P,Wang S,et al.Sepsis-Associated Acute Kidney Disease[J].Kidney Int Rep,2020,5(6):839-850.
[2]	Vijayan A.Tackling AKI:prevention,timing of dialysis and follow-up[J].Nat Rev Nephrol,2021,17(2):87-88.
[3]	Xu X,Nie S,Liu Z,et al.Epidemiology and Clinical Correlates of AKI in Chinese Hospitalized Adults[J].Clin J Am Soc Nephrol,2015,10(9):1510-1518.
[4]	Acedillo RR,Wald R,McArthur E,et al.Characteristics and Outcomes of Patients Discharged Home from an Emergency Department with AKI[J].Clin J Am Soc Nephrol,2017.
[5]	Piano S,Tonon M,Angeli P.Management of ascites and hepatorenal syndrome[J].Hepatol Int,2018,12(Suppl 1):122-134.
[6]	Jin K,Murugan R,Sileanu FE,et al.Intensive Monitoring of Urine Output Is Associated With Increased Detection of Acute Kidney Injury and Improved Outcomes[J].Chest,2017,152(5):972-979.
[7]	金魁,龙儒瑾,高志凌,等.脓毒症患者ICU延迟收住与急性肾损伤发病率及其相关死亡风险的研究[J].中国急救医学,2016,36(10):865-870.
[8]	Vincent JL,Sakr Y,Sprung CL,et al.Sepsis in European intensive care units:results of the SOAP study[J].Crit Care Med,2006,34(2):344-353.
[9]	Hu B,Xiang H,Dong Y,et al.Timeline of sepsis bundle component completion and its association with septic shock outcomes[J].J Crit Care,2020,60:143-151.
[10]	Liu C,Yan S,Wang Y,et al.Drug-Induced Hospital-Acquired Acute Kidney Injury in China:A Multicenter Cross-Sectional Survey[J].Kidney Dis(Basel),2021,7(2):143-155.
[11]	De Waele JJ,Boelens J,Leroux-Roels I.Multidrug-resistant bacteria in ICU:fact or myth[J].Curr Opin Anaesthesiol,2020,33(2):156-161.
[12]	Routsi C,Gkoufa A,Arvaniti K,et al.De-escalation of antimicrobial therapy in ICU settings with high prevalence of multidrug-resistant bacteria:a multicentre prospective observational cohort study in patients with sepsis or septic shock[J].J Antimicrob Chemother,2020,75(12):3665-3674.
[13]	Peerapornratana S,Manrique-Caballero CL,Gómez H,et al.Acute kidney injury from sepsis:current concepts,epidemiology,pathophysiology,prevention and treatment[J].Kidney Int,2019,96(5):1083-1099.
[14]	Poston JT,Koyner JL.Sepsis associated acute kidney injury[J].BMJ,2019,364:k4891.
[15]	Singbartl K,Formeck CL,Kellum JA.Kidney-Immune System Crosstalk in AKI[J].Semin Nephrol,2019,39(1):96-106.
[16]	Qian Q,Wu J,Wang J,et al.Prediction Models for AKI in ICU:A Comparative Study[J].Int J Gen Med,2021,14:623-632.
[17]	Shen KY,Chuang YC,Tung TH.Clinical Knowledge Supported Acute Kidney Injury(AKI)Risk Assessment Model for Elderly Patients[J].Int J Environ Res Public Health,2021,18(4):1607.
[18]	Barhight MF,Nelson D,Chong G,et al.Non-resuscitation fluid in excess of hydration requirements is associated with higher mortality in critically ill children[J].Pediatr Res,2021.
[19]	Zhao H,Long L,Wang Z,et al.Successful treatment of acute circulatory failure of unknown cause using critical ultrasound-guided reverse fluid resuscitation:A case report[J].Medicine(Baltimore),2020,99(51):e23594.
[20]	Akhter M,Potter T,Stowell J.The safety of the sepsis fluid bolus for patients at increased risk of volume overload[J].Am J Emerg Med,2021,41:6-8.
[21]	Lima L,Menon S,Goldstein SL,et al.Timing of Fluid Overload and Association With Patient Outcome[J].Pediatr Crit Care Med,2021,22(1):114-124.
[22]	Matalia J,Chandramouli A.Fluid overload[J].Indian J Ophthalmol,2021,69(4):793.
[23]	Huo Y,Lu ZB,Li B,et al.Ultrasonic evaluation of systemic and renal perfusion in sepsis patients before and after fluid resuscitation[J].Eur Rev Med Pharmacol Sci,2020,24(23):12450-12460.
[24]	Yi XL,Hu J,Wu QT,et al.Effect of Different-Volume Fluid Resuscitation on Organ Functions in Severe Acute Pancreatitis and Therapeutic Effect of Poria cocos[J].Evid Based Complement Alternat Med,2020,2020:6408202.
[25]	Cui Y,Yang Y,Lei W,et al.The clinicopathological features of drug-induced acute kidney injury-a single-center retrospective analysis[J].Ann Transl Med,2021,9(5):400.
[26]	Rolland AL,Garnier AS,Meunier K,et al.Drug-Induced Acute Kidney Injury:A Study from the French Medical Administrative and the French National Pharmacovigilance Databases Using Capture-Recapture Method[J].J Clin Med,2021,10(2):168.
[27]	金魁,徐军,于学忠.Sepsis与感染性休克的急诊救治及流程优化[J].协和医学杂志,2018,9(5):389-392.
[28]	Hanretty AM,Gallagher JC.Shortened Courses of Antibiotics for Bacterial Infections:A Systematic Review of Randomized Controlled Trials[J].Pharmacotherapy,2018,38(6):674-687.
[29]	Chen JJ,Kuo G,Hung CC,et al.Risk factors and prognosis assessment for acute kidney injury:The 2020 consensus of the Taiwan AKI Task Force[J].J Formos Med Assoc,2021.
[30]	Zang H,Liu F,Liu H,et al.Incidence,risk factors and outcomes of acute kidney injury(AKI) in patients with acute-on-chronic liver failure(ACLF) of underlying cirrhosis[J].Hepatol Int,2016,10(5):807-818.
[31]	Pan Y,Wang W,Wang J,et al.Incidence and Risk Factors of in-hospital mortality from AKI after non-cardiovascular operation:A nationwide Survey in China[J].Sci Rep,2017,7(1):13953.
[32]	Anders HJ,Wilkens L,Schraml B,et al.One concept does not fit all:the immune system in different forms of acute kidney injury[J].Nephrol Dial Transplant,2021,36(1):29-38.
[33]	Sun H,Depraetere K,Meesseman L,et al.A scalable approach for developing clinical risk prediction applications in different hospitals[J].J Biomed Inform,2021,118:103783.
[34]	Rank N,Pfahringer B,Kempfert J,et al.Deep-learning-based real-time prediction of acute kidney injury outperforms human predictive performance[J].NPJ Digit Med,2020,3:139.