切换至 "中华医学电子期刊资源库"

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:
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/OL]. 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/OL]. 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。

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.

表1 CCU患者的人口学资料及临床特征[±sM(P25P75)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 P
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(%)]
表3 186例CCU患者发生AKI的的多因素logistic回归分析
表4 186例CCU患者的临床转归[M(P25P75)或例数(%)]
表5 65例AKI患者中医病证的构成情况
表6 AKI组与非AKI组患者基本证候要素的比较[例数(%)]
[1]
Susantitaphong P, Cruz DN, Cerda J, et al. World incidence of AKI: a meta- analysis [J]. Clin J Am Soc Nephrol, 2013, 8(7): 1482-1493.
[2]
Lewington AJ, Cerda J, Mehta RL. Raising awareness of acute kidney injury:a global perspective of a silent killer [J]. Kidney Int, 2013, 84(3): 457-467.
[3]
Chertow GM, Burdick E, Honour M, et al. Acute kidney injury, mortality, length of stay, and costs in hospitalized patients [J]. J Am Soc Nephrol, 2005, 16(11): 3365-3370.
[4]
Chen TH, Chang CH, Lin CY, et al. Acute kidney injury biomarkers for patients in a coronary care unit: a prospective cohort study [J]. PLoS One, 2012, 7(2): e32328.
[5]
Kidney Disease: Improving Global Outcomes (KDIGO) Acute Kidney Injury Work Group. KDIGO clinical practice guideline for acute kidney injury [J]. Kidney Int Suppl, 2012, 2(1): 1-138.
[6]
Ma YC, Zuo L, Chen JH, et al. Modified glomerular filtration rate estimating equation for Chinese patients with chronic kidney disease [J]. J Am Soc Nephrol, 2006, 17(10): 2937-2944.
[7]
Goris RJ, te Boekhorst TP, Nuytinck JK, et al. Multiple-organ failure: generalized autodestructive inflammation? [J]. Arch Surg, 1985, 120(10): 1109-1115.
[8]
国家技术监督局.中华人民共和国国家标准:中医临床诊疗术语证候部分[M]. 北京:中国标准出版社,1997: 6.
[9]
Xiong J, Xi T, Hu Z, et al. The RIFLE versus AKIN classification for incidence and mortality of acute kidney injury in critical ill patients: a meta-analysis [J]. Sci Rep, 2015, 5(1): 17917.
[10]
Buargub M, Elmokhtar ZO. Incidence and mortality of acute kidney injury in patients with acute coronary syndrome: a retrospective study from a single coronary care unit [J]. Saudi J Kidney Dis Transpl, 2016, 27(4): 752-757.
[11]
赵春梅.急性心力衰竭患者的急性肾损伤:危险因素及其对临床预后的影响[D]. 南方医科大学,2010.
[12]
Kociol RD, Greiner MA, Hammill BG, et al. Long-term outcomes of medicare beneficiaries with worsening renal function during hospitalization for heart failure [J]. Am J Cardiol, 2010, 105(12): 1786-1793.
[13]
潘宏伟,郭莹,郑昭芬,等. 急性心肌梗死合并急性肾损伤的危险因素分析[J]. 中国动脉硬化杂志,2015, 23(12):1249-1252.
[14]
Palevsky PM, Liu KD, Brophy PD, et al. KDOQI US commentary on the 2012 KDIGO clinical practice guideline for acute kidney injury [J]. Am J Kidney Dis, 2013, 61(5): 649-672.
[15]
Yang L, Xing G, Wang L, et al. Acute kidney injury in China: a cross-sectional survey [J]. Lancet, 2015, 386(10002): 1465-1471.
[16]
Palomba H, Castro ID, Neto ALC, et al. Acute kidney injury prediction following elective cardiac surgery: AKICS score [J]. Kidney Int, 2007, 72(5): 624-631.
[17]
Queiroz REB, Albuquerque CAD, Santana CDA, et al. Acute kidney injury risk in patients with ST-segment elevation myocardial infarction at presentation to the ED [J]. Am J Emerg Med, 2012, 30(9): 1921-1927.
[18]
谌贻璞. 对高血压小动脉性肾硬化症诊断的思考[J]. 肾脏病与透析肾移植杂志,2004, 13(4):338-339.
[19]
王庆文,刘志红. 高尿酸血症与慢性肾脏病的关系[J]. 中华医学杂志,2012, 92(8):510-511.
[20]
Gottlieb SS, Brater DC, Thomas I, et al. BG9719 (CVT-124), an A1 adenosine receptor antagonist, protects against the decline in renal function observed with diuretic therapy [J]. Circulation, 2002, 105(11): 1348-1353.
[21]
周佩芳,卢娟娟,蔡楚丹,等. 前列腺素E1治疗慢性肾脏病基础上急性肾损伤的疗效观察[J]. 中国中西医结合肾病杂志,2011, 12(4):308-310.
[22]
杨晓君,边娜,李晓峰,等. 丹红注射液治疗心肾综合征33例临床观察[J].山东医药,2011, 51(45):78.
[23]
刘海虹,何玉中. 中西医结合治疗老年急性肾功能衰竭36例[J]. 辽宁中医杂志,2005, 32(1):62.
[1] 张婧琦, 江洋, 孙佳璐, 唐兴喆, 赵宇飞, 崔颖, 李信响, 戴景月, 傅琳, 彭新桂. 基于肾周CT特征结合血清肌酐水平探讨脓毒症伴急性肾损伤的早期识别[J/OL]. 中华危重症医学杂志(电子版), 2024, 17(04): 285-292.
[2] 樊恒, 孙敏, 朱建华. 红景天苷通过抑制PI3K/AKT/mTOR信号通路对大鼠脓毒症急性肾损伤的保护作用[J/OL]. 中华危重症医学杂志(电子版), 2024, 17(03): 188-195.
[3] 张锦丽, 席毛毛, 褚志刚, 栾夏刚, 陈诺, 王德运, 谢卫国. 大面积烧伤患者发生早期急性肾损伤的危险因素分析[J/OL]. 中华损伤与修复杂志(电子版), 2024, 19(04): 282-287.
[4] 彭瑞, 杨瑞文, 魏澹宁, 夏永良. 琥珀酸受体1加重肾脏缺血再灌注损伤的作用研究[J/OL]. 中华移植杂志(电子版), 2024, 18(03): 159-164.
[5] 中华医学会器官移植学分会, 中国医师协会器官移植医师分会. 中国肝移植受者肾损伤管理临床实践指南(2023版)[J/OL]. 中华肝脏外科手术学电子杂志, 2024, 13(03): 276-288.
[6] 杜霞, 马梦青, 曹长春. 造影剂诱导的急性肾损伤的发病机制及干预靶点研究进展[J/OL]. 中华肾病研究电子杂志, 2024, 13(05): 279-282.
[7] 郭俊楠, 林惠, 任艺林, 乔晞. 氨基酸代谢异常在急性肾损伤向慢性肾脏病转变中的作用研究进展[J/OL]. 中华肾病研究电子杂志, 2024, 13(05): 283-287.
[8] 袁楠, 黄梦杰, 白云凤, 李晓帆, 罗从娟, 陈健文. 急性肾损伤-慢性肾脏病转化小鼠模型制备的教学要点及学习效果分析[J/OL]. 中华肾病研究电子杂志, 2024, 13(04): 226-230.
[9] 林玲, 李京儒, 沈瑞华, 林惠, 乔晞. 基于生物信息学分析小鼠急性肾损伤和急性肺损伤的枢纽基因[J/OL]. 中华肾病研究电子杂志, 2024, 13(03): 134-144.
[10] 张轶男, 朱国贞. 急性肾损伤向慢性肾脏病转变研究进展[J/OL]. 中华肾病研究电子杂志, 2024, 13(02): 106-112.
[11] 周建芳, 罗旭颖, 张琳琳, 李宏亮, 杨燕琳, 陈光强, 石广志. 开颅术后危重患者急性肾损伤的发病率、危险因素及其对预后的影响[J/OL]. 中华重症医学电子杂志, 2024, 10(02): 148-156.
[12] 司楠, 孙洪涛. 创伤性脑损伤后肾功能障碍危险因素的研究进展[J/OL]. 中华脑科疾病与康复杂志(电子版), 2024, 14(05): 300-305.
[13] 沈炎, 张俊峰, 唐春芳. 预后营养指数结合血清降钙素原、胱抑素C及视黄醇结合蛋白对急性胰腺炎并发急性肾损伤的预测价值[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(06): 536-540.
[14] 崔秋子, 姚红曼, 艾迎春. 监测NLR、PLR、CAR、白蛋白、血钙及血糖指标水平对急性胰腺炎患者急性肾损伤的预测价值分析[J/OL]. 中华消化病与影像杂志(电子版), 2024, 14(03): 244-248.
[15] 颜世锐, 熊辉. 感染性心内膜炎合并急性肾损伤患者的危险因素探索及死亡风险预测[J/OL]. 中华临床医师杂志(电子版), 2024, 18(07): 618-624.
阅读次数
全文


摘要