高龄老年人发生持续急性肾损伤危险因素及临床特点分析

doi:10.3877/cma.j.issn.2095-3216.2019.06.006

目的

了解短暂急性肾损伤(AKI)与持续AKI发生率；比较两组AKI患者的临床特征，分析老年人发生持续AKI相关危险因素。

方法

回顾性分析2007年1月至2018年12月就诊于解放军总医院国家老年疾病临床医学研究中心≥75岁住院患者的病例资料744例。根据发生AKI后48 h时血肌酐(Scr)恢复情况将患者分为短暂AKI与持续AKI进行分析。采用SPSS 17.0软件进行统计分析。多因素Logistic回归分析老年人发生持续AKI的相关危险因素。

结果

744例老年AKI患者中，男性701例，占94.2%，中位年龄88 (84～91)岁。8.3%的患者为短暂AKI (62/744)，91.7%的患者为持续AKI (682/744)。两组患者比较，持续AKI患者较短暂AKI患者的高血压病史比例高(72.4%与83.9%, P＝0.041) ，90 d病死率高(37.4%与8.1%, P<0.001)、AKI 3期所占比例高(33.1%与8.1%, P<0.001)，确诊时Scr (130.0与116.1 μmol/L, P<0.001)、Scr峰值(147.6与117.9 μmol/L, P<0.001)、血尿素氮(13.1与9.3 mmol/L, P<0.001)、尿酸(368.1与338.3 μmol/L, P＝0.006)、血钠(141与138 mmol/L, P<0.001)水平高。持续AKI患者伴有机械通气(42.5%与12.9%, P<0.001)、低蛋白血症(34.1±5.6与36.1±5.3 g/L, P＝0.006)、贫血(111±22与119±20 g/L, P＝0.009)等情况明显增多。多因素Logistic回归分析显示：Scr峰值(OR＝1.011; 95%CI: 1.004～1.019; P＝0.002)、血钠高(OR＝1.055; 95% CI: 1.015～1.097; P＝0.007)、机械通气(OR＝2.912; 95%CI: 1.334～6.357; P＝0.007)是高龄老年患者发生持续AKI的独立危险因素。

结论

高龄老年患者持续AKI的发生率高达92%，早期诊断和治疗危险因素可减少肾脏的持续损伤。

关键词: 急性肾损伤, 短暂急性肾损伤, 持续急性肾损伤, 老年人, 危险因素

Objective

To investigate the incidence of transient acute kidney injury (AKI) and persistent AKI, the clinical characteristics of AKI patients, and the risk factors associated with persistent AKI in the elderly.

Methods

A retrospective analysis of 744 cases of ≥75-year-old inpatients who attended the National Geriatrics Clinical Research Center of the Chinese PLA General Hospital from January 2007 to December 2018. According to the recovery of serum creatinine (Scr) at 48 hours after AKI, the patients were divided into transient AKI group and persistent AKI group. SPSS 17.0 software was used for statistical analysis. Multivariate logistic regression method was used to analyze the risk factors related to persistent AKI in the elderly.

Results

Among the 744 cases of elderly patients with AKI, 701 cases were male (94.2%) with a median of 88 years (84-91). 8.3% of the patients suffered from transient AKI (62/744) and 91.7% of the patients persistent AKI (682/744). Compared with the transient group, the persistent AKI group showed a higher proportion of patients with a hypertension history (72.4% vs 83.9%, P=0.041), a higher 90-day mortality rate (37.4% vs 8.1%, P<0.001). a higher proportion of patients with AKI stage 3 (33.1% vs 8.1%, P<0.001), and higher levels of Scr (130.0 vs 116.1 μmol/L, P<0.001), peak Scr (147.6 vs 117.9 μmol/L, P<0.001), BUN (13.1 vs 9.3 mmol/L, P<0.001), serum uric acid (368.1 vs 338.3 μmol/L, P=0.006), and serum sodium (141 vs 138 mmol/L, P<0.001) on diagnosis of AKI. Compared with the transient group, the persistent AKI group also had more patients with mechanical ventilation (42.5% vs 12.9%, P<0.001), hypoalbuminemia (34.1±5.6 and 36.1±5.3 g/L, P=0.006), and anemia (111±22 vs 119±20 g/L, P=0.009). Multivariate logistic regression analysis showed that the peak Scr (OR=1.011, 95%CI: 1.004-1.019, P=0.002), increased serum sodium (OR=1.055, 95%CI: 1.015-1.097, P=0.007), and mechanical ventilation (OR=2.912, 95%CI: 1.334-6.357, P=0.007) were independent risk factors for the development of persistent AKI in the elderly patients.

Conclusion

The incidence of persistent AKI in the elderly patients was as high as 92%, and early diagnosis and treatment of risk factors could reduce persistent kidney damage.

Key words: Acute kidney injury, Transient AKI, Persistent AKI, Elderly, Risk factor

表1 短暂AKI与持续AKI两组患者的一般情况

组别	例数	一般情况			基础疾病及肾功能
组别	例数	年龄(岁)	男性[例(%)]	BMI(kg/m²)	冠心病	COPD	高血压	糖尿病	基础Scr(μmol/L)	基础eGFR
短暂AKI	62	87(84～91)	57 (91.9)	22.6±4.1	51(82.3)	43(69.4)	52(83.9)	26(41.9)	70.0(60.0～80.0)	80.2(75.0～85.5)
持续AKI	682	88(84～91)	644 (94.4)	23.0±3.0	514(75.4)	468(68.6)	494(72.4)	257(37.7)	72.0(60.0～83.0)	78.6(71.8～85.3)
t值或χ²值	－	－0.753	0.587	0.823	1.477	0.014	4.187	0.436	－0.780	－0.948
P值	－	0.451	0.443	0.413	0.224	0.905	0.041	0.509	0.435	0.343

表1 短暂AKI与持续AKI两组患者的一般情况

组别	例数	一般情况			基础疾病及肾功能
组别	例数	年龄(岁)	男性[例(%)]	BMI(kg/m²)	冠心病	COPD	高血压	糖尿病	基础Scr(μmol/L)	基础eGFR
短暂AKI	62	87(84～91)	57 (91.9)	22.6±4.1	51(82.3)	43(69.4)	52(83.9)	26(41.9)	70.0(60.0～80.0)	80.2(75.0～85.5)
持续AKI	682	88(84～91)	644 (94.4)	23.0±3.0	514(75.4)	468(68.6)	494(72.4)	257(37.7)	72.0(60.0～83.0)	78.6(71.8～85.3)
t值或χ²值	－	－0.753	0.587	0.823	1.477	0.014	4.187	0.436	－0.780	－0.948
P值	－	0.451	0.443	0.413	0.224	0.905	0.041	0.509	0.435	0.343

表2 短暂AKI与持续AKI两组患者的临床特征

组别	例数	AKI病因						伴随情况
组别	例数	脓毒症	低血容量	心血管事件	肾毒性药物	手术	其他	少尿	机械通气	平均动脉压
短暂AKI	62	19 (30.6)	12 (19.4)	15(24.2)	4(6.5)	9(14.5)	3(4.8)	2(3.2)	8(12.9)	81±14
持续AKI	682	29(43.0)	147(21.6)	96(14.1)	85(12.5)	40(5.9)	21(3.1)	44(6.5)	290(42.5)	78±14
t值或χ²值	－	3.541	0.164	4.583	1.950	5.419	0.497	1.205	20.765	－1.572
P值	－	0.060	0.686	0.032	0.163	0.020	0.481	0.272	<0.001	0.116
组别	例数	AKI确诊时实验室检查结果
组别	例数	Scr(μmol/L)	Scr峰值(μmol/L)	BUN(mmol/L)	血尿酸(μmol/L)	血钠(mmol/L)	血清白蛋白(g/L)	血清前白蛋白(g/L)	血红蛋白(g/L)
短暂AKI	62	116.1(107.0～134.9)	117.9(109.8～136.2)	9.3(7.2～12.8)	338.3(268.9～419.4)	138.0(132.0～142.0)	36.1±5.3	187(143～235)	119±20
持续AKI	682	130.0(116.0～146.0)	147.6(126.0～213.3)	13.1(9.2～21.4)	368.1(294.7～471.5)	141.0(136.0～147.0)	34.1±5.6	174(134～227)	111±22
t值或χ²值	－	－3.652	－6.429	－4.719	－2.693	－3.649	－2.780	－1.260	－2.606
P值	－	<0.001	<0.001	<0.001	0.006	<0.001	0.006	0.208	0.009
组别	例数	AKI分期			90 d结局
组别	例数	1期	2期	3期	病死率	透析
短暂AKI	62	39(62.9)	18(29.0)	5(8.1)	5(8.1)	0
持续AKI	682	284(41.6)	172(25.2)	226(33.1)	255(37.4)	4(0.6)
t值或χ²值	－	17.749			21.499	0.698
P值	－	<0.001			<0.001	0.403

表2 短暂AKI与持续AKI两组患者的临床特征

组别	例数	AKI病因						伴随情况
组别	例数	脓毒症	低血容量	心血管事件	肾毒性药物	手术	其他	少尿	机械通气	平均动脉压
短暂AKI	62	19 (30.6)	12 (19.4)	15(24.2)	4(6.5)	9(14.5)	3(4.8)	2(3.2)	8(12.9)	81±14
持续AKI	682	29(43.0)	147(21.6)	96(14.1)	85(12.5)	40(5.9)	21(3.1)	44(6.5)	290(42.5)	78±14
t值或χ²值	－	3.541	0.164	4.583	1.950	5.419	0.497	1.205	20.765	－1.572
P值	－	0.060	0.686	0.032	0.163	0.020	0.481	0.272	<0.001	0.116
组别	例数	AKI确诊时实验室检查结果
组别	例数	Scr(μmol/L)	Scr峰值(μmol/L)	BUN(mmol/L)	血尿酸(μmol/L)	血钠(mmol/L)	血清白蛋白(g/L)	血清前白蛋白(g/L)	血红蛋白(g/L)
短暂AKI	62	116.1(107.0～134.9)	117.9(109.8～136.2)	9.3(7.2～12.8)	338.3(268.9～419.4)	138.0(132.0～142.0)	36.1±5.3	187(143～235)	119±20
持续AKI	682	130.0(116.0～146.0)	147.6(126.0～213.3)	13.1(9.2～21.4)	368.1(294.7～471.5)	141.0(136.0～147.0)	34.1±5.6	174(134～227)	111±22
t值或χ²值	－	－3.652	－6.429	－4.719	－2.693	－3.649	－2.780	－1.260	－2.606
P值	－	<0.001	<0.001	<0.001	0.006	<0.001	0.006	0.208	0.009
组别	例数	AKI分期			90 d结局
组别	例数	1期	2期	3期	病死率	透析
短暂AKI	62	39(62.9)	18(29.0)	5(8.1)	5(8.1)	0
持续AKI	682	284(41.6)	172(25.2)	226(33.1)	255(37.4)	4(0.6)
t值或χ²值	－	17.749			21.499	0.698
P值	－	<0.001			<0.001	0.403

表3 影响老年持续AKI的多因素Logistic回归分析

Risk factor	OR	95%CI	P值
机械通气(0/1)	2.912	1.334～6.357	0.007
血钠(mmol/L)	1.055	1.015～1.097	0.007
Scr峰值(μmol/L)	1.011	1.004～1.019	0.002

表3 影响老年持续AKI的多因素Logistic回归分析

Risk factor	OR	95%CI	P值
机械通气(0/1)	2.912	1.334～6.357	0.007
血钠(mmol/L)	1.055	1.015～1.097	0.007
Scr峰值(μmol/L)	1.011	1.004～1.019	0.002

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Analysis of risk factors and clinical characteristics of elderly patients with persistent acute kidney injury

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Analysis of risk factors and clinical characteristics of elderly patients with persistent acute kidney injury