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中华肾病研究电子杂志

中华肾病研究电子杂志 ›› 2018, Vol. 07 ›› Issue (03) : 116 -121. doi: 10.3877/cma.j.issn.2095-3216.2018.03.005

所属专题： 文献；

论著

CCU患者发生急性肾损伤的现状调查及中医证候研究
张雯1, 孙鲁英1,†(), 张笑笑1, 张立晶2, 郑启艳1, 王娅辉1, 赵庆1   
  1. 1. 100700　北京中医药大学东直门医院肾病科
    2. 100700　北京中医药大学东直门医院心血管内科
  • 收稿日期:2017-11-27 出版日期:2018-06-28
  • 通信作者: 孙鲁英

Investigation on the status quo of acute kidney injury incidence in CCU patients and TCM syndromes analysis

Wen Zhang1, Luying Sun1,†(), Xiaoxiao Zhang1, Lijing Zhang2, Qiyan Zheng1, Yahui Wang1, Qing Zhao1   

  1. 1. Department of Nephrology; Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
    2. Department of Cardiology; Dongzhimen Hospital, Beijing University of Chinese Medicine, Beijing 100700, China
  • Received:2017-11-27 Published:2018-06-28
  • Corresponding author: Luying Sun
  • About author:
    Corresponding author: Sun Luying, Email:
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引用本文：

张雯, 孙鲁英, 张笑笑, 张立晶, 郑启艳, 王娅辉, 赵庆. CCU患者发生急性肾损伤的现状调查及中医证候研究[J]. 中华肾病研究电子杂志, 2018, 07(03): 116-121.

Wen Zhang, Luying Sun, Xiaoxiao Zhang, Lijing Zhang, Qiyan Zheng, Yahui Wang, Qing Zhao. Investigation on the status quo of acute kidney injury incidence in CCU patients and TCM syndromes analysis[J]. Chinese Journal of Kidney Disease Investigation(Electronic Edition), 2018, 07(03): 116-121.

目的

调查中医院冠心病重症监护室(CCU)患者急性肾损伤(AKI)的发生情况及中医证候特点。

方法

回顾性研究北京中医药大学东直门医院2015年1月1日到2015年12月31日入住CCU的患者，采用KDIGO指南推荐的AKI诊断标准，将患者分为AKI组和非AKI组，比较两组的人口学资料及临床特征、治疗、转归、中医证候特点，并用多因素Logistic回归分析AKI发生的危险因素。

结果

共纳入186例患者，发生AKI 65例(35.0%)，漏诊率为89.2%。①人口学资料及临床基本特征：年龄、发生多脏器功能衰竭、尿素氮、血肌酐(Scr)在AKI组明显高于非AKI组(P<0.001)；N末端脑钠肽(NT-BNP)升高、双下肢水肿、合并高血压、高尿酸血症在AKI组高于非AKI组(P<0.05)；②治疗：利尿剂在AKI组的使用明显高于非AKI组(χ2＝17.729，P<0.001); ③多因素Logistic回归分析显示使用利尿剂(OR＝6.980，CI 2.287～21.306)、eGFR<90 ml/(min·1.73 m2)(OR＝2.201，CI 1.076～4.504)、发生非肾多脏器功能衰竭(OR＝3.733，CI 1.602～8.702)是AKI发生的独立危险因素；④转归：院内死亡在AKI组明显高于非AKI组(χ2＝16.510，P<0.001)、出院Scr在AKI组明显高于非AKI组(Z＝－7.683，P<0.001)；⑤中医证候：水停证在AKI组高于非AKI组(χ2＝0.024，P<0.05)；在虚证中，气虚出现频率最高、其次为阴虚；在实证中，血瘀出现频率最高、其次为痰证；AKI患者虚实夹杂所占比例最高(50.8%)。

结论

中医院CCU患者AKI的发生存在着高发病率、高漏诊率的特点。临床治疗中应谨慎使用大剂量利尿剂、注重肾脏及其它重要脏器的保护。中医治疗应注重"心肾同治"及"标本兼顾"，以益气养阴，活血化瘀为主，兼用利水化痰。

关键词: 急性肾损伤, 冠心病重症监护室, 中医证候
Objective

To investigate the incidence of acute kidney injury (AKI) in the coronary care unit (CCU) of the hospital of Chinese medicine and the characteristics of traditional Chinese medicine (TCM) syndromes.

Methods

A retrospective clinical study was performed in the patients admitted into the CCU of Dongzhimen Hospital Affiliated to Beijing University of Chinese Medicine from January 1, 2015 to December 31, 2015. The patients were divided into AKI group and non-AKI group according to the diagnosis criteria of AKI recommended by KDIGO guidelines. The two groups were compared in demographic data, clinical features, treatment, clinical outcome, and TCM symptoms. Multivariate logistic regression method was used to analyze risk factors of AKI.

Results

Total 186 cases were enrolled in this study, including 65 cases (34.5%) of AKI, and the rate of missed diagnosis was 89.2%. ①Demographic data and clinical features: The ages, multiple organ failure incidences, and levels of urea nitrogen and serum creatinine (Scr) were significantly higher in the AKI group than in the non-AKI group (P<0.001); The incidences of N-terminal pro-B-type natriuretic peptide (NT-BNP) increase, lower extremity edema, hypertension, and hyperuricemia were higher in the AKI group than in the non-AKI group (P<0.05). ②Treatment: The incidence of diuretics use was significantly higher in the AKI group than in the non-AKI group (χ2=17.729, P<0.001). ③Multivariate logistic regression analysis showed that the diuretics use (OR=6.980, CI 2.287-21.306), eGFR <90 ml/(min·1.73 m2) (OR=2.201, CI 1.076-4.504), and non-renal multiple organ failure (OR=3.733, CI 1.602-8.702) were the independent risk factors of AKI. ④Clinical outcomes: In the AKI group, both the hospital mortality rate (χ2=16.510, P<0.001) and the Scr at discharge (Z=-7.683, P<0.001) were significantly higher than those in the non-AKI group. ⑤TCM syndromes: The incidence of water stagnation syndrome was higher in the AKI group than in the non-AKI group (χ2=0.024, P<0.05). Among the deficiency syndromes, the incidence of Qi deficiency syndrome was the highest, while the incidence of Yin deficiency syndrome the second highest. Among the excess syndromes, the incidence of blood stagnation syndrome was the highest, and the incidence of phlegm syndrome the second highest. The incidence of intermingled deficiency and excess (50.8%) was the highest among all syndromes in the AKI group.

Conclusions

The occurrence of AKI in the CCU of the hospital of Chinese medicine was featured with high incidence rate and high missed diagnosis rate. In clinical treatment, high-dose diuretics should be used with caution, emphasizing on the protection of kidneys and other vital organs. For TCM therapy, attention should be paid to "simultaneous treatment of heart and kidney" for "both symptoms and root causes" , with a focus on tonifying the Qi and nourishing the Yin, and activating the blood and dissolving the stasis, as well as excreting the water and eliminating the phlegm.

Key words: Acute kidney injury, Coronary care unit, TCM syndromes
表1 CCU患者的人口学资料及临床特征[±s、M(P25，P75)或例数(%)]
项目 急性肾损伤组(n＝65) 非急性肾损伤组(n＝121) t/Z/χ2值 P值
年龄(岁) 78.0(67.5，83.0) 67.0(55.5，76.0) －4.125 <0.001
男性 35(53.8) 79(65.3) 2.334 0.127
心脏疾病首次发作 27(41.5) 73(60.3) 6.007 0.014
左心室射血分数(%) 54.5(41.0，62.0) 56.0(50.5，64.0) 1.543 0.123
收缩压(mmHg) 132.2±23.7 130.1±23.0 0.579 0.563
舒张压(mmHg) 68.0(63.5，80.0) 73.0(65.0，82.0) 1.789 0.074
双下肢水肿 27(41.5) 29(24.0) 6.584 0.010
高血压 48(73.8) 71(58.7) 4.222 0.040
糖尿病 27(41.5) 44(36.4) 0.480 0.489
入院eGFR<90 ml/(min·1.73 m2) 49(75.4) 62(51.2) 10.244 0.010
心脏病类型 ? ? 6.297 0.178
? 急性冠脉综合征 37(56.9) 72(59.6) ? ?
? 心功能不全 23(35.4) 27(22.3) ? ?
? 心律失常 3(4.6) 16(13.2) ? ?
? 冠心病 1(1.5) 4(3.3) ? ?
? 其他 1(1.5) 2(1.7) ? ?
发生多脏器功能衰竭 21(32.3) 13(10.7) 13.163 <0.001
基线实验室检查 ? ? ? ?
? N末端脑钠肽升高 39(65.0) 49(43.8) 7.061 0.008
? 血红蛋白(g/L) 118.0(97.5，141.5) 129.0(111.0，143.0) 1.803 0.071
? 血糖(mmol/L) 8.0(6.0，10.0) 7.0(5.8，8.8) －1.589 0.112
? 血钾(mmol/L) 4.00(4.0，5.0) 4.00(4.0，4.4) -0.460 0.645
? 血钠(mmol/L) 139.0(135.0，141.0) 139.4(137.0，142.0) 1.163 0.245
? 乳酸脱氢酶(IU/L) 231.0(162.5，310.0) 209.0(153.5，332.0) -0.713 0.476
? 尿素氮(mmol/L) 8.0(6.00，13.0) 6.0(5.0，8.0) -4.764 <0.001
? 血肌酐(μmol/L) 105.0(69.0，156.5) 75.0(61.8，93.9) -3.884 <0.001
? 尿酸(μmol/L) 399.1±136.8 357.8±134.0 1.990 0.048
表2 CCU患者的治疗情况[例数(%)]
项目 急性肾损伤组(n＝65) 非急性肾损伤组(n＝121) χ2值 P值
血管紧张素转换酶抑制剂 24(36.9) 47(38.8) 0.066 0.797
血管紧张素Ⅱ受体拮抗剂 20(30.8) 37(30.6) 0.001 0.979
血管扩张剂 55(84.6) 88(72.7) 3.362 0.067
强心剂 26(40.0) 35(28.9) 2.353 0.125
利尿剂 61(93.8) 80(66.1) 17.729 <0.001
中药汤剂 36(55.4) 58(47.9) 0.939 0.333
输血 3(4.6) 1(0.8) 2.885 0.089
肾脏替代治疗 2(3.1) 3(2.5) 0.058 0.810
表3 186例CCU患者发生AKI的的多因素logistic回归分析
? 发生急性肾损伤
P值 OR 95%CI
利尿剂(使用与未使用) 0.001 6.980 2.287～21.306
eGFR<90 ml/(min·1.73 m2)与≥90 ml/(min·1.73 m2) 0.031 2.201 1.076～4.504
发生非肾多脏器功能衰竭(是与否) 0.002 3.733 1.602～8.702
表4 186例CCU患者的临床转归[M(P25，P75)或例数(%)]
项目 急性肾损伤组(n＝65) 非急性肾损伤组(n＝121) Z/χ2 P值
院内死亡 13(20.0) 3(2.5) 16.510 <0.001
出院血肌酐(μmol/L) 157.0(107.5，219.5) 84.0(67.5，105.5) －7.683 <0.001
住院天数(d) 10.0(7.0，14.0) 9.0(6.0，12.0) －1.574 0.116
表5 65例AKI患者中医病证的构成情况
证候要素 例数(f) 总例数(n) 构成比(f/n)%
单纯虚证 6 65 9.2
单纯实证 26 65 40.0
虚实夹杂 33 65 50.8
表6 AKI组与非AKI组患者基本证候要素的比较[例数(%)]
证候要素 急性肾损伤组(n＝65) 非急性肾损伤组(n＝121) χ2值 P值
气虚 28(43.1) 47(38.8) 0.315 0.575
血虚 9(13.8) 13(10.7) 0.390 0.097
阴虚 11(16.9) 13(10.7) 1.437 0.230
阳虚 9(13.8) 9(7.4) 1.987 0.159
火热 2(3.1) 5(3.4) 0.130 0.718
血瘀 32(49.2) 48(39.7) 1.577 0.209
痰证 29(44.6) 60(49.6) 0.419 0.518
水停 12(18.5) 9(7.4) 5.130 0.024
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