Analysis of effects and influencing factors of continuous renal replacement therapy in severe burn patients complicated with acute kidney injury
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摘要:
目的 初步评价连续性肾脏替代治疗（CRRT）对严重烧伤合并急性肾损伤（AKI）患者的疗效并分析其影响因素。 方法 该研究为回顾性病例系列研究。2010年1月—2020年12月，陆军军医大学（第三军医大学）第一附属医院收治79例符合入选标准的接受CRRT的严重烧伤合并AKI患者。统计全部患者的一般资料（后同），包括性别、年龄、体重指数、烧伤面积、烧伤指数、致伤原因、是否合并吸入性损伤、入院时急性生理学和慢性健康状况评价Ⅱ（APACHE Ⅱ）和脓毒症相关性器官功能衰竭评价（SOFA）评分、烧伤后入院时间和入院后发生AKI时间；CRRT整体效果，包括总体有效率、完全有效率、部分有效率、无效率、恶化率，治疗前后的肌酐、尿素、胱抑素C、液体超载率，院内病死率、基于Baux评分模型的预测病死率、最常见的死亡原因、住院天数。根据CRRT效果，将患者分为有效组（42例）和无效组（37例），比较2组患者的一般资料和发生AKI后启动CRRT时间、CRRT持续时间、AKI病因、CRRT启动前AKI分期、CRRT模式、抗凝剂种类、院内病死率。筛选严重烧伤合并AKI患者CRRT效果的独立影响因素。根据AKI病因，将患者分为肾前性组（22例）和肾性组（57例），比较2组患者一般资料和发生AKI后启动CRRT时间、CRRT持续时间和CRRT整体效果（最常见的死亡原因除外）。 结果 79例患者中，男73例、女6例，年龄（46±14）岁，体重指数（24.0±2.9）kg/m2，烧伤总面积（69±26）%体表总面积（TBSA），Ⅲ度烧伤面积（44±25）%TBSA，烧伤指数57（36，76）。火焰烧伤者36例、电烧伤者19例、热液烫伤者16例、爆炸伤者6例、化学烧伤者2例，39例患者合并吸入性损伤，入院时APACHE Ⅱ评分16（12，18）分、SOFA评分11（5，13）分，烧伤后0（0，2）d入院，入院后0（0，6）d发生AKI。CRRT总体有效率53.16%（42/79）、完全有效率30.38%（24/79）、部分有效率22.78%（18/79）、无效率31.65%（25/79）、恶化率15.19%（12/79）。患者治疗后的肌酐和尿素均明显低于治疗前（Z值分别为-3.26、-2.54，P<0.05）；治疗后的胱抑素C和液体超载率与治疗前比较，差异均无统计学意义（P>0.05）。患者院内病死率17.72%（14/79），基于Baux评分模型的预测病死率75.10%（18.94%，91.84%），最常见的死亡原因为多器官功能衰竭，住院天数39.43（11.52，110.58）d。有效组和无效组患者Ⅲ度烧伤面积、CRRT持续时间、AKI病因比较，差异均有统计学意义（Z值分别为-1.99、-2.90，χ2=5.58，P<0.05）；其余指标比较，差异均无统计学意义（P>0.05）。AKI病因和Ⅲ度烧伤面积均是严重烧伤合并AKI患者CRRT效果的独立影响因素（比值比分别为4.21和1.03，95%置信区间分别为1.20~14.80和1.00~1.05，P<0.05）。肾前性组和肾性组患者的致伤原因、CRRT总体有效率、烧伤总面积、烧伤指数、烧伤后入院时间、入院后发生AKI时间、发生AKI后启动CRRT时间和基于Baux评分模型的预测病死率比较，差异均有统计学意义（χ2值分别为12.59、5.58，Z值分别为2.46、2.43、-2.43、-4.03、-3.01、-2.31，P<0.05）；肾性组患者治疗前的尿素和胱抑素C均明显高于肾前性组（Z值分别为-2.98、-2.77，P<0.05），液体超载率明显低于肾前性组（Z=-2.99，P<0.05）；肾性组患者治疗后的胱抑素C明显高于肾前性组（Z=-2.08，P<0.05）；其余指标比较，差异均无统计学意义（P>0.05）。 结论 CRRT在严重烧伤合并AKI患者中可明显改善患者肾功能、避免液体超载、缓解肾脏损伤等，肾前性AKI是导致CRRT无效的主要独立影响因素。 Abstract:Objective To preliminarily evaluate the effects and analyze the influencing factors of continuous renal replacement therapy (CRRT) in severe burn patients complicated with acute kidney injury (AKI). Methods This study was a retrospective case series study. From January 2010 to December 2020, 79 severe burn patients complicated with AKI who received CRRT and met the inclusion criteria were admitted to the First Affiliated Hospital of Army Medical University (the Third Military Medical University). The general data (the same below) of all patients were collected, including gender, age, body mass index, burn area, burn index, cause of injury, whether combined with inhalation injury, acute physiology and chronic health status evaluation Ⅱ (APACHE Ⅱ) score and sepsis-related organ failure assessment (SOFA) score on admission, admission time after burn, and time of AKI after admission. The total efficacy of CRRT, including overall effective rate, complete effective rate, partial effective rate, ineffective rate, and deterioration rate, creatinine, urea, cystatin C, and fluid overload rate before and after treatment, in-hospital mortality, predictive mortality based on Baux scoring model, the most common cause of death, and length of hospital stay were recorded. According to the effect of CRRT, the patients were divided into effective group (42 patients) and ineffective group (37 patients). The general information of patients, the time to initiate CRRT after the occurrence of AKI, the duration of CRRT, etiology of AKI, AKI stage before CRRT initiation, CRRT mode, anticoagulant type, and in-hospital mortality were compared between the two groups of patients. The independent influencing factors for CRRT in severe burn patients complicated with AKI were screened. According to the etiology of AKI, the patients were divided into prerenal group (22 patients) and renal group (57 patients). The general information of patients, the time to initiate CRRT after the occurrence of AKI, the duration of CRRT, and total efficacy of CRRT (except for the most common cause of death) were compared between the two groups of patients. Results Among the 79 patients, 73 cases were male and 6 cases were female, with age of (46±14) years, body mass index of (24.0±2.9) kg/m2, total burn area of (69±26)% total body surface area (TBSA), full-thickness burn area of (44±25)%TBSA, and burn index of 57 (36, 76). There were 36 cases of flame burns, 19 cases of electrical burns, 16 cases of hydrothermal burns, 6 cases of explosive burns, and 2 cases of chemical burns. Thirty-nine patients were complicated with inhalation injury. The APACHE Ⅱ score was 16 (12, 18) and the SOFA score was 11 (5, 13) on admission. The patients were admitted to the hospital on 0 (0, 2) d after burn, and AKI occurred on 0 (0, 6) d after admission. The overall effective rate of CRRT was 53.16% (42/79), the complete effective rate was 30.38% (24/79), the partial effective rate was 22.78% (18/79), the ineffective rate was 31.65% (25/79), and the deterioration rate was 15.19% (12/79). The creatinine and urea of patients after treatment were significantly lower than those before treatment (with Z values of -3.26 and -2.54, respectively, P<0.05); there were no statistically significant differences in the cystatin C and fluid overload rate of patients before and after treatment (P>0.05). The in-hospital mortality of patients was 17.72% (14/79), and the predictive mortality based on Baux scoring model was 75.10% (18.94%, 91.84%). The most common cause of death was multiple organ failure, and the length of hospital stay was 39.43 (11.52, 110.58) d. There were statistically significant differences in the full-thickness burn area, the duration of CRRT, and etiology of AKI of patients between effective group and ineffective group (with Z values of -1.99 and -2.90, respectively, χ2=5.58, P<0.05). There were no statistically significant differences in the other indicators (P>0.05). The etiology of AKI and full-thickness burn area were the independent influencing factors for CRRT in severe burn patients complicated with AKI (with odds ratios of 4.21 and 1.03, respectively, 95% confidence intervals of 1.20-14.80 and 1.00-1.05, respectively, P<0.05). There were statistically significant differences in the cause of injury, overall effective rate of CRRT, total burn area, burn index, admission time after burn, time of AKI after admission, the time to initiate CRRT after the occurrence of AKI, and predictive mortality based on Baux score model of patients between prerenal group and renal group (with χ2 values of 12.59 and 5.58, respectively, Z values of 2.46, 2.43, -2.43, -4.03, -3.01, and -2.31, respectively, P<0.05). Before treatment, urea and cystatin C of patients in renal group were significantly higher than those in prerenal group (with Z values of -2.98 and -2.77, respectively, P<0.05), and the liquid overload rate was significantly lower than that in prerenal group (Z=-2.99, P<0.05); after treatment, the cystatin C of patients in renal group was significantly higher than that in prerenal group (Z=-2.08, P<0.05); there were no statistically significant differences in the other indicators (P>0.05). Conclusions CRRT can significantly improve renal function, avoid fluid overload, and alleviate renal injury in severe burn patients complicated with AKI. Prerenal AKI is the main independent influencing factor leading to ineffective CRRT. -
参考文献
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表1 有效组和无效组严重烧伤合并AKI患者的一般资料和CRRT相关资料比较
表1. Comparison of general data and CRRT-related data in the severe burn patients complicated with AKI between effective group and ineffective group
组别 例数 性别（例） 年龄（岁， 体重指数（kg/m2， 烧伤总面积（%TBSA， Ⅲ度烧伤面积［%TBSA，M（Q1，Q3）］ 烧伤指数［M（Q1，Q3）］ 男 女 有效组 42 39 3 47±12 24.3±3.1 69±29 42（26，75） 58（36，82） 无效组 37 34 3 46±16 24.3±4.3 64±25 37（20，52） 51（34，73） 统计量值 — t=0.30 t=-0.01 t=1.22 Z=-1.99 Z=-1.59 P值 >0.999 0.761 0.993 0.225 0.046 0.111 注：有效组患者CRRT效果等级为完全有效或部分有效，无效组患者CRRT效果等级为无效或恶化；AKI为急性肾损伤，CRRT为连续性肾脏替代治疗，TBSA为体表总面积，APACHE Ⅱ为急性生理学和慢性健康状况评价Ⅱ，SOFA为脓毒症相关性器官功能衰竭评价，CVVH为连续性静脉-静脉血液滤过，CVVHDF为连续性静脉-静脉血液透析滤过；“—”表示无此项；CRRT模式中其他为混合使用CVVH和CVVHDF或单独使用连续性静脉-静脉血液透析，抗凝剂种类中其他为混合使用肝素或枸橼酸抗凝剂或使用除这2种抗凝剂之外的抗凝剂 
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表2 影响79例严重烧伤合并AKI患者CRRT效果的多因素logistic回归分析结果
表2. Results of multivariate logistic regression analysis affecting the efficacy of CRRT in 79 severe burn patients complicated with AKI
项目与分类 比值比 95%置信区间 P值 常量 0.07 — 0.002 AKI病因 肾性AKI（以肾前性AKI为参照） 4.21 1.20~14.80 0.025 Ⅲ度烧伤面积（%TBSA） 1.03 1.00~1.05 0.024 发生AKI后启动CRRT时间（h） 1.33 0.87~2.03 0.182 CRRT持续时间（h） 1.00 0.99~1.00 0.186 注：AKI为急性肾损伤，CRRT为连续性肾脏替代治疗，TBSA为体表总面积；“—”表示无此项
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表3 肾前性组和肾性组严重烧伤合并AKI患者一般资料和CRRT相关时间参数比较
表3. Comparison of general data and CRRT-related time indexes in the severe burn patients complicated with AKI between prerenal group and renal group
组别 例数 性别（例） 年龄（岁， 体重指数（kg/m2， 烧伤总面积［%TBSA，M（Q1，Q3）］ Ⅲ度烧伤面积［%TBSA，M（Q1，Q3）］ 烧伤指数［M（Q1，Q3）］ 致伤原因（例） 男 女 火焰烧伤 电烧伤 爆炸伤 化学烧伤 热液烫伤 肾前性组 22 20 2 46±12 24.4±2.8 90（70，95） 54（34，70） 73（54，80） 13 0 2 1 6 肾性组 57 53 4 46±14 24.2±4.0 62（40，86） 34（20，59） 47（32，67） 23 19 4 1 10 统计量值 — t=-0.09 t=0.15 Z=2.46 Z=1.82 Z=2.43 χ2=12.59 P值 >0.999 0.924 0.877 0.016 0.072 0.017 0.007 注：肾前性和肾性为AKI病因；AKI为急性肾损伤，CRRT为连续性肾脏替代治疗，TBSA为体表总面积，APACHE Ⅱ为急性生理学和慢性健康状况评价Ⅱ，SOFA为脓毒症相关性器官功能衰竭评价；“—”表示无此项
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表4 肾前性组和肾性组严重烧伤合并AKI患者CRRT效果比较
表4. Comparison of efficacy of CRRT in the severe burn patients complicated with AKI between prerenal group and renal group
组别 例数 总体有效情况［例（%）］ CRRT效果等级［例（%）］ 完全有效 部分有效 无效 恶化 肾前性组 22 7（31.82） 4（18.18） 3（13.64） 11（50.00） 4（18.18） 肾性组 57 35（61.40） 20（35.09） 15（26.32） 14（24.56） 8（14.04） 统计量值 χ2=5.58 χ2=-1.92 P值 0.024 0.054 注：肾前性和肾性为AKI病因；AKI为急性肾损伤，CRRT为连续性肾脏替代治疗
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