高龄老年患者急性肾损伤后肾功能恢复调查及危险因素分析:652例报告

Outcomes of renal function and risk factors in elderly patients with acute kidney injury:analysis of 652 cases

摘要:

目的 了解高龄老年急性肾损伤(AKI)患者肾功能恢复率,临床特点及肾功能未恢复的危险因素,分析不同AKI病因对老年患者短期预后的影响及不同AKI分期与肾功能恢复的关系。方法 回顾性分析2007年1月至2015年12月就诊于解放军总医院老年病房≥75岁的AKI患者652例,随访90 d,根据生存情况将患者分为生存组和死亡组,生存患者按肾功能恢复情况分为恢复组和未恢复组。收集患者基本资料、临床特征(诊断时间、平均动脉压、尿量、透析、机械通气、实验室指标和持续性AKI比例)、AKI分期及AKI病因。应用SPSS 17.0软件对数据进行分析,根据数据类型,两组间比较采用t检验、Mann-Whitney U检验、χ²检验或Fisher精确检验；AKI患者肾功能恢复的危险因素分析采用多因素logistic回归法(向前法)。结果 患者中位年龄87(84~91)岁,随访90 d病死率为33.6%(219/652),存活的433例患者中,肾功能恢复组316例(73%,316/433),未恢复组117例(27%,117/433)。感染、血容量不足、心血管事件、肾毒性药物和外科手术是老年人医院获得性AKI的主要病因,其中死亡组发生感染比例明显高于生存组(53.0% vs 33.0%；P<0.001),肾毒性药物使用率明显低于生存组(5.5% vs 15.2%；P=0.001),差异均有统计学意义。恢复组基本资料与未恢复组相比,糖尿病史比例较高,基础血清肌酐(SCr)值较低,基础估算的肾小球滤过滤(eGFR)较高,差异均有统计学意义(P<0.01)。恢复组临床特征与未恢复组相比,AKI诊断时间较短,确诊AKI时SCr及SCr峰值水平较低,血尿素氮(BUN)水平较高,透析需要率和持续性AKI比例降低,差异均有统计学意义(P＜0.05)；恢复组AKI分期与未恢复组相比,差异无统计学意义(P＞0.05)。多因素logistic回归分析显示基础eGFR升高(OR=0.897,5%CI 0.842~0.956; P=0.001)是影响高龄老年AKI患者90 d肾功能恢复的保护因素；持续性AKI(OR=4.497,5%CI 2.774~7.290; P<0.001)是肾功能未恢复的危险因素。结论 临床医师要识别影响老年AKI预后的关键病因,即感染及应用肾毒性药物,关注基础eGFR降低及持续性AKI的存在情况,及早检测、早期干预可能会改善老年AKI患者的肾脏预后。

Abstract:

Objective To investigate the complete recovery rate of renal function, clinical characteristics and risk factors for non-recovery in the elderly with acute kidney injury (AKI), determine the effect of different causes on the short-term prognosis, and investigate the relationship of different stages of AKI with renal function recovery. Methods A retrospective cohort study was carried out on 652 elderly AKI patients (≥75 years old) who hospitalized in our geriatric wards from January 2007 to December 2015. After 90 days’ follow-up, these patients were divided into survival group and death group, and the former group was further assigned into recovery group and non-recovery group according to their renal function. Basic information, clinical data (diagnostic time, mean arterial pressure, urine volume, dialysis, mechanical ventilation, observation indicators and ratio of persistent AKI), AKI stages and causes were collected and analyzed. SPSS statistics 17.0 was used for data processing. Student’s t test, Mann-Whitney U test, Chi-sqaure test or Fisher’s exact test was used for comparison of different data types between groups. Multivariate logistic regression analysis (forward) was adopted to analyze the risk factors of renal function recovery. Results The median age of the 652 patients was 87(84 to 91) years. The mortality rate of the cohort was 33.6%(219/652). Among the 433 survivals, 316 patients (73%,316/433) got complete recovery in renal function, and the other 117 cases (27%, 117/433) did not recover. Infection, hypovolemia, cardiova-scular events, nephrotoxicity, and surgery were the common causes for hospital acquired AKI in the elderly. The incidence of infection (53.0% vs 33.0%; P<0.001) was significantly higher, while the ratio of using nephrotoxic drugs (5.5% vs 15.2%; P=0.001) was obviously lower in the death group than the survival group. For the survived patients, the recovery subgroup had higher ratio of diabetes mellitus, lower baseline serum creatinine (SCr), higher basal estimated glomerular filtration rate (eGFR) than the non-recovery subgroup (P<0.01). Furthermore, the recovery subgroup also had shorter time for diagnosis of AKI, lower peak level and SCr level at diagnosis, higher level of blood urea nitrogen (BUN), and lower ratios of dialysis requirement and persistent AKI (P<0.05). But there was no significant difference in AKI stage between the 2 subgroups (P>0.05). Multivariate logistic regression analysis showed that increased basal eGFR (OR=0.897,5%CI:0.842-0.956; P=0.001) was a protective factor for renal function recovery, while persistent AKI (OR=4.497,5%CI:2.774-7.290; P<0.001) was a risk factor for renal function recovery in elderly patients with AKI at 90 d after diagnosis. Conclusion Clinicians should identify the key causes influencing the prognosis of elderly AKI, that is, infection and application of nephrotoxic drugs, and concern about decreased basal eGFR and persistent AKI. What’s more, early detection and intervention may improve the prognosis of elderly AKI patients.