老年人医院获得性急性肾损伤的临床特点及用药分析

Clinical characteristics and medications for hospital-acquired acute kidney injury in the elderly patients

摘要:

目的 研究老年病房住院患者院内获得性急性肾损伤(HA-AKI)的临床特点及相关用药情况。方法 回顾性分析2012 年1月到 2016年12月广东省人民医院≥60岁的老年病房住院患者7029例。按全球肾脏病预后组织(KDIGO)标准中血肌酐变化情况判断HA-AKI,其中HA-AKI患者1830例(HA-AKI组),非AKI患者4650例(AKI组)。比较2组患者的临床特点、可能致肾毒性药物的使用情况,以及相关药物使用与住院结局的关系。采用SPSS 20.0统计软件进行数据分析。依据数据类型,组间比较分别采用t检验、χ²检验或趋势检验。结果 老年病房HA-AKI发生率为26.0%(1830/7029)。与非AKI组比较,HA-AKI组患者年龄、基础血肌酐以及估算肾小球滤过率＜60 ml/(min·1.73 m²)、Charlson并发症指数≥3分、糖尿病、慢性肾脏病、周围血管病、脑血管病变及结缔组织病的比例均显著增加(P<0.001)；同时利尿剂或脱水剂、肾上腺素受体激动剂、抗心力衰竭及糖肽类抗生素等药物在HA-AKI组的使用比例更高。住院结局中,HA-AKI组患者需转ICU[6.0%(110/1830) vs 1.5%(68/4650)]、心肺复苏[0.7%(12/1830) vs 0.3%(12/4650)]、血液透析[2.0%(36/1830) vs 0.1%(1/4650)]的比例,以及住院时间[(15.9±6.5) vs (13.6±6.5)d]、住院费用[(5.7±4.0)×10⁴ vs (4.4±2.9)×10⁴ RMB￥]、病死率[11.3%(207/1830) vs 0.9%(41/4650)]显著高于非AKI组(P<0.05)。发病后HA-AKI组患者使用利尿剂及脱水剂、血管紧张素转化酶抑制剂或血管紧张素受体拮抗剂、非甾体抗炎药、肾上腺素受体激动剂、糖肽类抗生素、化疗药的比例不减反增。随用药种类增加,HA-AKI组患者不良结局均有趋势性增加(P<0.001)。结论 老年病房HA-AK发生率较高,可能原因为年龄大、共病多、且发病前所涉及的肾毒性药物种类多,导致住院不良结局及医疗负担增加。

Abstract:

Objective To investigate the clinical characteristics of and medications for hospital-acquired acute kidney injury (HA-AKI) in the patients in geriatric wards. Methods A retrospective analysis was made of 7029 hospitalized patients aged over 60 years in the Geriatric Ward of Guangdong General Hospital from January 2012 to December 2016. According to the criteria of serum creatinine (SCr) change in Kidney Disease:Improving Global Outcomes(KDIGO), patients were divided into HA-AKI group (n=1830)and non-AKI group (n=4650). The 2 groups were compared in clinical characteristics, use of drugs that may cause nephrotoxicity, and relationship between use of drugs and discharge outcomes. SPSS statistics 20.0 was used for statistical analysis. Depending on data type, Student′s t test, χ² or trend tests were used for comparison. Results The incidence of HA-AKI was 26.03%(1830/7029). Compared with non-AKI group, HA-AKI group had more advanced age, higher baseline SCr, higher percentage of patients with estimated glomerular filtration rate (eGFR)＜60 ml/(min·1.73 m²), higher incidence of chronic kidney disease, diabetes mellitus, connective tissue disease, cerebrovascular disease, and peripheral vascular disease, and higher Charlson comorbidity index (CCI) score≥3 (P<0.001). The HA-AKI groups also had a higher proportion of nephrotoxic drugs such as diuretic and dehydrating agent, adrenergic receptor agonists, anti-heart failure drugs and aminoglycosides than the non-AKI group. In addition, the HA-AKI group were higher than the non-AKI [JP+1]group in the percentage of patients requiring transfer to ICU [6.0%(110/1830) vs1.5%(68/4650)],cardio-pulmonary resuscitation [0.7%(12/1830) vs 0.3%(12/4650)] and dialysis [2.0% (36/1830) vs 0.1%(1/4650)], length of hospital stay [(15.9±6.5) vs (13.6±6.5)d] and hospitalization costs [(5.7±4.0)×10⁴ vs (4.4±2.9)×10⁴ RMB￥]and in-hospital mortality [11.3%(207/1830) vs 0.9%(41/4650)] (P<0.05). Moreover, the use of diuretic and dehydrating agent, angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin receptor blockers (ARBs), non-steroidal anti-inflammatory drugs (NSAIDs), adrenergic receptor agonists, aminoglycosides, and chemotherapeutic agent continued to increase even after the occurrence of HA-AKI, and the greater the number of the drugs used, the worse the tendency of the in-hospital adverse outcomes (P<0.001). Conclusion Incidence of HA-AKI is high in geriatric wards, which is attributable to the higher age, more comorbidities and number of nephrotoxic drugs used before the onset, causing serious outcomes and increasing burden on medical care.