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中华肾病研究电子杂志 ›› 2022, Vol. 11 ›› Issue (05) : 258 -263. doi: 10.3877/cma.j.issn.2095-3216.2022.05.003

论著

并发肾衰竭的新冠肺炎患者临床特征和死亡风险分析
余艳1, 陈客宏1, 戴欢子1, 肖菲2,()   
  1. 1. 400042 重庆,陆军特色医学中心肾内科;430042 武汉泰康同济新冠肺炎专科医院重症医学科
    2. 400042 重庆,陆军特色医学中心肾内科
  • 收稿日期:2021-12-14 出版日期:2022-10-28
  • 通信作者: 肖菲
  • 基金资助:
    重庆市自然科学基金项目(cstc2020jcyj-msxmX0013)

Analysis of clinical features and risk of death in COVID-19 patients complicated with renal failure

Yan Yu1, Kehong Chen1, Huanzi Dai1, Fei Xiao2,()   

  1. 1. Department of Nephrology, Army Specialty Medical Center, Chongqing 400042; Department of Critical Care Medicine, Taikang Tongji COVID-19 Hospital, Wuhan 430042, Hubei Province; China
    2. Department of Nephrology, Army Specialty Medical Center, Chongqing 400042
  • Received:2021-12-14 Published:2022-10-28
  • Corresponding author: Fei Xiao
引用本文:

余艳, 陈客宏, 戴欢子, 肖菲. 并发肾衰竭的新冠肺炎患者临床特征和死亡风险分析[J/OL]. 中华肾病研究电子杂志, 2022, 11(05): 258-263.

Yan Yu, Kehong Chen, Huanzi Dai, Fei Xiao. Analysis of clinical features and risk of death in COVID-19 patients complicated with renal failure[J/OL]. Chinese Journal of Kidney Disease Investigation(Electronic Edition), 2022, 11(05): 258-263.

目的

本研究旨在分析肾衰竭新冠肺炎患者疾病临床特征和死亡风险。

方法

纳入2020年2月3日至2020年4月10日武汉市泰康同济新冠肺炎专科医院收治的1 412例新冠肺炎患者进行研究。根据eGFR[ml/(min·1.73 m2)]将研究对象分为3组:正常肾功能组(eGFR ≥ 90);肾功能不全组(60 ≤ eGFR<90);肾衰竭组(eGFR<60)。分析其临床表现、实验室指标、并发症和预后。

结果

正常肾功能组1 086例(76.9%),肾功能不全组258例(18.3%),肾衰竭组68例(4.8%)。患者平均年龄为62岁(50~70岁),男性为650例(46.0%)。与正常肾功能组相比,肾功能不全组和肾衰竭组患者年龄较大,肾衰竭组患者发生气短和胸闷症状更多,但是出现发热和咳痰症状的比例却更低(P<0.05)。肾衰竭组患者患有高血压、糖尿病、冠心病、脑血管疾病的比例最高。与正常肾功能组相比,肾衰竭组患者的炎症相关指标(C反应蛋白、白细胞介素-6)和凝血功能指标(纤维蛋白原、D-二聚体)显著升高,但淋巴细胞计数、血小板计数、血红蛋白、白蛋白明显降低(P<0.05)。肾衰竭组患者更多需要肾脏支持治疗(6.0%)、抗生素治疗(55.2%)和糖皮质激素治疗(18.2%),更容易出现各种严重并发症,包括呼吸衰竭、急性呼吸窘迫综合征、急性心力衰竭、急性心脏损伤、凝血障碍、脓毒症、休克、贫血、低蛋白血症、电解质紊乱和酸中毒(P<0.05)。随着基线肾功能的降低,患者的死亡比例逐渐升高(P<0.05),肾衰竭组患者死亡率高达18.5%。多因素Cox回归分析发现,与正常肾功能组相比,肾衰竭组死亡风险升高7.873倍(95%CI:2.110~29.376,P=0.002)。

结论

并发肾衰竭的新冠肺炎患者,心脑并发症发生率高,死亡率高,更加需要肾脏支持、抗生素和糖皮质激素治疗等。

Objective

The purpose of this study was to analyze the clinical characteristics of disease and the risk of death in COVID-19 patients complicated with renal failure.

Methods

A total of 1412 patients with COVID-19 in Taikang Tongji COVID-19 Hospital from February 3, 2020 to April 10, 2020 were included in the study. The patients were divided into three groups based on eGFR (mL/min/1.73 m2): normal renal function group (eGFR ≥ 90), renal insufficiency group (60 ≤ eGFR < 90), renal failure group (eGFR < 60). The clinical manifestations, laboratory indicators, complications, and prognosis were analyzed.

Results

There were 1086 cases (76.9%) in the normal renal function group, 258 cases (18.3%) in the renal insufficiency group, and 68 cases (4.8%) in the renal failure group. The mean age of the patients was 62 years (50-70 years), and 650 cases (46.0%) were males. Compared with the normal renal function group, patients of the renal insufficiency group and the renal failure group were older, and patients of the renal failure group showed higher proportion of shortness of breath and chest tightness, but less fever and expectoration (P<0.05). The renal failure patients showed the highest proportion of hypertension, diabetes, coronary heart disease, and cerebrovascular disease. Compared with normal renal function group, the renal failure group displayed higher levels of inflammation-related indexes (C-reactive protein, interleukin-6) and coagulation function indexes (fibrinogen, D-dimer), while the lymphocyte count, platelet count, hemoglobin, and albumin were significantly decreased (P<0.05). Patients of the renal failure group were more likely to need renal support therapy (6.0%), antibiotic therapy (55.2%), and glucocorticoid therapy (18.2%), and were more prone to various serious complications, including respiratory failure, acute respiratory distress syndrome, acute heart failure, acute cardiac injury, coagulopathy, sepsis, shock, anemia, hypoproteinemia, electrolyte disorder, and acidosis (P<0.05). With the decrease of baseline renal function, the mortality rate of patients increased gradually (P<0.05), and the mortality rate of the renal failure group was up to 18.5%. Multivariate Cox regression analysis found that the risk of death in patients with renal failure was significantly increased by 7.873 times that of the normal renal function group (95%CI: 2.110-29.376, P=0.002).

Conclusion

COVID-19 patients complicated with renal failure had a higher incidence of cardiocerebral complications and higher mortality rate, requiring more renal support, antibiotics, and glucocorticoid therapy, etc.

表1 不同肾功能状态新冠肺炎患者的临床特征
指标 患者数量(n=1 412) 正常肾功能组(n=1 086) 肾功能不全组(n=258) 肾衰竭组(n=68) F/χ2 P
年龄(年) 62(50,70) 60(47,67) 74(64,81)a 71.5(62,81)a 86.285 <0.001c
男性(%) 650/1412(46.0) 507/1086(46.68) 115/258(44.57) 28/68(41.17) 1.503 0.591d
体质指数(kg/m2) 23.4(21.2,25.5) 23.4(21.3,25.6) 23.3(21.5,25.3) 22.6(20.1,25.9) 0.073 0.929c
收缩压(mmHg) 130(120,142) 130(120,141) 135(124,147) 130(117,146) 1.917 0.820c
舒张压(mmHg) 80(74,88) 80(74,88) 80(74,89) 78(66,91) 1.338 0.736c
疾病分型比例[占比(%)]            
  普通型 995/1412(70.5) 820/1086(75.5) 149/258(57.8)a 26/68(38.2)ab 67.242 <0.001d
  重型和危重型 415/1412(29.5) 264/1086(24.4) 109/258(42.4)a 42/68(61.7)ab 68.503 <0.001d
临床症状比例[占比(%)]            
  发热 808/1412(57.1) 639/1086(58.8) 133/258(51.5) 31/68(45.5) 8.223 0.016d
  咳嗽 755/1412(53.7) 594/1086(54.7) 134/258(51.9) 27/68(39.7)a 6.078 0.048d
  咳痰 223/1412(15.9) 180/1086(16.6) 37/258(14.3) 6/68(8.8) 3.391 0.183d
  乏力 518/1412(36.9) 387/1086(35.6) 105/258(40.7) 26/68(38.2) 2.374 0.305d
  气短 309/1412(22.0) 229/1086(21.1) 61/258(23.64) 19/68(27.9) 2.331 0.312d
  畏寒 149/1412(8.0) 108/1086 (7.8) 27/258(7.5) 14/68(12.5)a 7.683 0.021d
  咽痛 179/1412(9.7) 137/1086 (9.9) 22/258(9.2) 9/68(8.0) 3.445 0.179d
  胸闷 307/1412(16.6) 222/1086 (16.1) 69/258(19.2) 16/68(14.3) 5.000 0.082d
  厌食 72/1412(5.1) 51/1086(4.67) 19/258(7.4) 2/68(2.9) 3.391 0.186d
合并症[占比(%)]            
  高血压 540/1412(38.3) 354/1086(32.6) 144/258(55.8)a 42/68(61.8)a 64.315 <0.001d
  糖尿病 234/1412(16.6) 160/1086(14.8) 56/258(21.7)a 18/68(26.5)a 12.393 0.002
  冠心病 164/1412(11.6) 90/1086(8.3) 54/258(20.9)a 20/68(29.4)a 54.503 <0.001d
  脑血管疾病 106/1412(7.5) 65/1086(6.0) 33/258(12.8)a 8/68(11.8)a 15.770 <0.001d
表2 不同肾功能状态新冠肺炎患者的实验室检查和影像学表现
入院时的化验结果 患者数量(n=1 412) 正常肾功能组(n=1 086) 肾功能不全组(n=258) 肾衰竭组(n=68) F/χ2 P
血液学            
  白细胞计数(×109/L) 5.78(4.72,6.92) 5.69(4.69,6.85) 5.98(4.84,7.03) 6.365(4.90,8.85) 1.623 0.130c
  淋巴细胞计数(×109/L) 1.6(1.23,2.1) 1.7(1.31, 2.16) 1.4(1.06,1.86)a 1.2(0.88,1.95)a 6.090 <0.001c
  血小板计数(×109/L) 216(181,123) 220(184, 267) 208(166,253)a 208.5(174,240.25)a 4.644 0.001c
  血红蛋白(g/L) 119(109,132) 121(110, 133) 115(103,127) 110.5 (89,122)a 10.119 <0.001c
  肌酐(μmol/L) 54.44(44.51,67.07 50.03(41.76, 59.01) 72.26(62.4,82.74) 117.96(91.58,152.33)ab 358.416 <0.001c
  尿素(mmol/L) 4.93(4.07,5.99) 4.69(3.92, 5.59) 5.7(4.58,6.99) 9.29(6.97,14.32)ab 135.521 <0.001c
  白蛋白(g/L) 38.21(34.88,40.95) 38.56(35.71,41.25) 36.8(33.42,39.91) 34.95(30.86,38.76)a 32.099 <0.001c
  总胆红素(mmol/L) 10.77(8.51,13.74) 10.7(8.46, 13.41) 11.29(8.68,15.29) 10.6(8.94,14.60) 1.009 0.120c
感染相关性指标            
  c反应蛋白(mg/L) 0.50(0.50,3.57) 0.50(0.50, 2.70) 0.50(0.50,3.56) 2.15(0.50,18.93)ab 8.112 <0.001c
  白介素6(pg/ml) 2.95(1.50,7.09) 2.42(1.50, 5.20) 2.95(1.50,7.09) 9.67(4.89,22.79)ab 9.322 <0.001c
  降钙素原(ng/ml) 0.043(0.027,0.072) 0.039(0.025, 0.061) 0.043(0.027,0.072) 0.10(0.04,0.36)ab 3.294 0.001c
凝血功能            
  前凝血酶时间(s) 12.1(11.4,12.9) 12.1(11.4, 12.8) 12.1(11.4,12.9) 12.2(11.4,13.4) 1.202 0.211c
  活化部分凝血活酶时间(s) 31.4(29.2,34) 31.5(29.37, 34) 31.4(29.2,34) 31.7(29.5,33) 1.926 0.115c
纤维蛋白原(mg/dl) 287(240,346) 283 (237, 341) 287(240,346) 329.5(266.75,388.5)ab 4.715 <0.001c
  D-二聚体(ng/ml) 161(47,495) 117(38.75, 428) 161(47,495) 421(271,1416)ab 6.733 <0.001c
尿常规[占比(%)]            
  尿蛋白阳性 135/1027(13.1) 81/796(1 0.2) 34/187(18.2) 20/44(45.5)a 50.532 <0.001d
  尿隐血阳性 243/1027(23.8) 181/796(22.8) 45/187(24.2) 17/44(38.6) 5.779 0.056d
CT影像学异常[占比(%)]            
  胸膜下肺炎 116/1412(8.2) 101/1086(9.3) 12/258(4.7)a 3/68(4.4) 7.340 0.025f
  单侧肺炎 112/1412(7.9) 92/1086(8.5) 17/258(6.6) 3/68(4.4) 1.861 0.390f
  双侧肺炎 778/1412(55.1) 570/1086(52.5) 163/258(63.2)a 45/68(66.2)a 13.177 0.001d
表3 不同肾功能状态新冠肺炎患者的治疗、并发症和临床预后
治疗、并发症和临床预后 患者数量(n=1 412) 正常肾功能组(n=1 086) 肾功能不全组(n=258) 肾衰竭组(n=68) F/χ2 P
治疗[占比(%)]            
  鼻导管/面罩吸氧 814/1412(57.6) 627/1086(57.7) 153/258(59.3) 24/68(35.3) 6.705 0.035c
  高流量吸氧 88/1412(6.2) 61/1086(5.6) 17/258(6.6) 10/68(14.7)ab 12.019 0.002c
  无创呼吸机 22/1412(1.6) 12/1086(1.1) 5/258(1.9) 5/68(7.4)ab 11.726 0.002c
  有创机械通气 23/1412(1.6) 12/1086(1.1) 7/258(2.7) 4/68(5.9)ab 9.784 0.005d
  连续性血液净化 9/1398(0.6) 1/1076(0.1) 4/255(1.6)a 4/67(6.0)ab 22.671 <0.001d
  激素 108/1386(7.8) 76/1067(7.1) 20/253(7.9) 12/66(18.2)ab 10.585 0.005c
并发症[占比(%)]            
  呼吸衰竭 37/1406(2.6) 19/1082(1.6) 9/256(3.5) 9/68(13.2)ab 33.858 <0.001c
  急性呼吸窘迫综合征 17/1407(1.2) 7/1083(0.6) 5/256(2.0) 5/68(7.4)a 16.094 <0.001d
  急性心衰 27/1407(1.9) 11/1083(1.0) 10/256(3.9)a 6/68(8.8)a 27.290 <0.001c
  急性肾损伤 80/1373(5.8) 59/1059(5.6) 11/250(4.4) 10/64(15.6)ab 9.621 0.008c
  凝血紊乱 616/1053(58.5) 450/807(55.7) 129/195(66.2)a 37/51(72.5)a 11.343 0.003c
  贫血 809/1409(57.4) 592/1083(54.7) 168/258(65.1)a 49/68(72.1)a 15.577 <0.001c
  低蛋白血症 361/1410(25.6) 230/1084(21.2) 97/258(37.6)a 34/68(50.0)a 51.678 <0.001c
  电解质紊乱 226/1365(16.6) 148/1048(14.1) 55/250(22.0)a 23/67(34.3)a 25.174 <0.001c
  酸中毒 22/1378(1.6) 12/1061(1.1) 5/251(2.0) 5/66(7.6)ab 11.228 0.003d
临床预后[占比(%)]            
  出院 1275/1412 (90.3) 1001/1086 (92.2) 227/258(88.0) 47/68 (69.1)ab 49.387 <0.001c
  住院 100/1412(7.1) 41/1086 (3.8) 10/258 (3.9) 8/68 (11.8)ab 11.056 0.004c
  死亡 21/1412(1.5) 3/1086(0.3) 8/258(3.1)a 10/68(14.7)ab 49.703 <0.001d
  入重症监护 86/1412(6.1) 48/1086(4.4) 21/258(8.1) 17/68(25.0)ab 49.970 <0.001c
  有创机械通气 28/1412(1.9) 17/1086(1.5) 7/258(2.7) 4/68(5.8)a 6.378 0.032d
表4 不同肾小球滤过率水平新冠肺炎患者死亡风险的多因素Cox回归分析
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