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中华肾病研究电子杂志

中华肾病研究电子杂志 ›› 2025, Vol. 14 ›› Issue (04) : 196 -203. doi: 10.3877/cma.j.issn.2095-3216.2025.04.003

论著

终末期肾病合并脓毒症患者临床特征及预后影响因素分析
陈亚磊1, 卢年芳1, 刘安琪1, 刘虎南1, 赵培宏1, 陈健文2,†()   
  1. 1100073　北京，首都医科大学北京电力教学医院（国家电网公司北京电力医院）重症医学科
    2100853　北京，解放军总医院第一医学中心肾脏病医学部、肾脏疾病全国重点实验室、国家慢性肾病临床医学研究中心、重症肾脏疾病器械与中西医药物研发北京市重点实验室、数智中医泛血管疾病防治北京市重点实验室、国家中医药管理局高水平中医药重点学科(zyyzdxk-2023310)
  • 收稿日期:2025-05-06 出版日期:2025-08-28
  • 通信作者: 陈健文
  • 基金资助:
    北京市丰台区卫生健康系统科研项目(2023-86)

Analysis of clinical characteristics and prognostic factors in patients with end-stage renal disease complicated with sepsis

Yalei Chen1, Nianfang Lu1, Anqi Liu1, Hunan Liu1, Peihong Zhao1, Jianwen Chen2,†()   

  1. 1Department of Critical Care Medicine, Electric Power Teaching Hospital of Capital Medical University / Beijing Electric Power Hospital of State Grid Corporation, Beijing 100073
    2Department of Nephrology, First Medical Center of Chinese PLA General Hospital, State Key Laboratory of Kidney Diseases, National Clinical Research Center for Kidney Diseases, Beijing Key Laboratory of Medical Devices and Integrated Traditional Chinese and Western Drug Development for Severe Kidney Diseases, Beijing Key Laboratory of Digital Intelligent TCM for Prevention and Treatment of Pan-vascular Diseases, Key Disciplines of National Administration of Traditional Chinese Medicine (zyyzdxk-2023310), Beijing 100853; China
  • Received:2025-05-06 Published:2025-08-28
  • Corresponding author: Jianwen Chen
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引用本文：

陈亚磊, 卢年芳, 刘安琪, 刘虎南, 赵培宏, 陈健文. 终末期肾病合并脓毒症患者临床特征及预后影响因素分析[J/OL]. 中华肾病研究电子杂志, 2025, 14(04): 196-203.

Yalei Chen, Nianfang Lu, Anqi Liu, Hunan Liu, Peihong Zhao, Jianwen Chen. Analysis of clinical characteristics and prognostic factors in patients with end-stage renal disease complicated with sepsis[J/OL]. Chinese Journal of Kidney Disease Investigation(Electronic Edition), 2025, 14(04): 196-203.

目的

分析重症监护室(intensive care unit, ICU)终末期肾病(end-stage renal disease, ESRD)合并脓毒症患者的临床特征及预后影响因素。

方法

回顾性分析重症监护医学信息数据库Ⅳ(medical information mart for intensive care IV, MIMIC-IV)中在2008年至2022年入住ICU的ESRD合并脓毒症患者，收集其人口学特征、生命体征、实验室指标、合并症、院内诊疗操作、疾病严重程度评分、终点指标等资料。根据患者入住ICU后30 d的生命状态将其分为存活组和死亡组。比较两组患者的临床特征，采用多因素Logistic回归法筛选患者进入ICU后1个月的生存风险因素；并构建回归模型、绘制受试者工作特征曲线，探讨其对预后的预测作用。

结果

共纳入患者1 214例，入ICU后1月内死亡318例，死亡率26.2%。与存活组相比，死亡组患者的年龄较大、心率和呼吸更快、平均动脉压更低，而简化急性生理评分Ⅱ、序贯器官衰竭评估及牛津急性疾病严重程度评分更高(P均<0.05)。多因素Logistic分析显示，较高的年龄，较高的红细胞分布宽度、乳酸、查尔森合并症指数、序贯器官衰竭评估评分以及合并脑血管疾病是患者死亡的独立危险因素，而较高的碱剩余水平和透析治疗则是保护因素。预测模型受试者工作特征曲线下面积为0.79，敏感度0.69，特异度0.76，显著高于单独序贯器官衰竭评估、简化急性生理评分Ⅱ或牛津急性疾病严重程度评分的预测。

结论

在ESRD合并脓毒症患者入住ICU期间，应关注其红细胞分布宽度、乳酸、碱剩余、查尔森合并症指数、序贯器官衰竭评估等指标的变化，对患者进行充分透析，并积极预防脑血管疾病等并发症。

关键词: 终末期肾病, 脓毒症, 重症监护, 预后, 影响因素
Objective

To analyze the clinical characteristics and prognostic factors of patients with end-stage renal disease (ESRD) complicated with sepsis in the intensive care unit (ICU).

Methods

A retrospective analysis was conducted on ICU patients with ESRD complicated with sepsis form 2008 to 2022 of the medical information mart for intensive care IV (MIMIC-IV, v3.0) database. Data on demographic characteristics, vital signs, laboratory indicators, comorbidities, hospital-based diagnostic and therapeutic procedures, disease severity scores, and endpoint indicators were collected. The patients were divided into the survival group and non-survival group based on their 30-day survival status after ICU admission. The clinical characteristics of the two groups of patients were compared, and a multi-factor logistic regression analysis was used to screen for risk factors affecting patient survival within one month after ICU admission. A regression model was constructed, and a receiver operating characteristic (ROC) curve was plotted to explore its predictive effect on prognosis.

Results

A total of 1, 214 patients were included, and 318 died within one month after admission to the ICU, with a mortality rate of 26.2%. Compared to the survival group, patients in the non-survival group had significantly older age, higher heart and respiratory rates, lower mean arterial pressure, and elevated scores in the simplified acute physiology score Ⅱ (SAPS Ⅱ), sequential organ failure assessment (SOFA), and Oxford acute severity of illness score (OASIS) (all P<0.05). Multivariate logistic analysis revealed that older age, higher levels of red blood cell distribution width, lactic acid, Charlson comorbidity index, and SOFA score, as well as complication with cerebrovascular disease were independent risk factors for the patients mortality, while higher base excess and dialysis acted as protective factors. The prediction model achieved an area under the ROC curve of 0.79, with a sensitivity of 0.69 and a specificity of 0.76, significantly outperforming the predictive performance of SOFA, SAPS Ⅱ, or OASIS alone.

Conclusion

During the ICU stay of the patients with ESRD complicated with sepsis, clinicians should monitor changes in red cell distribution width, lactate, base excess, Charlson comorbidity index, and SOFA, ensure adequate dialysis, and actively prevent complications such as cerebrovascular disease.

Key words: End-stage renal disease, Sepsis, Intensive care, Prognosis, Influencing factors
图1 病例筛选流程注：ICU：重症监护室；CKD：慢性肾脏病；eGFR：估算的肾小球滤过率；左侧虚线部分为可选的排除步骤方案，与右侧排除方案可二选一，显示此虚线部分，可得到脓毒症患病率等数据
表1 终末期肾病合并脓毒症重症监护室住院患者临床特征分析
项目 全体(1 214例) 存活组(896例) 死亡组(318例) P值
人口学特征        
性别(男性)[例(%)] 726(59.8) 536(59.8) 190(59.7) 1.000
年龄(岁) 67.20(56.82, 76.27) 65.25(54.88, 74.30) 72.50(62.47, 79.95) <0.010
体质量指数(kg/m2) 27.80(24.00, 32.52) 27.90(24.00, 32.80) 27.20(23.80, 32.42) 0.517
生命体征        
心率(次/min) 83.90(74.43, 95.90) 82.70(74.30, 95.00) 86.85(75.53, 98.90) 0.005
呼吸(次/min) 18.90(16.50, 21.80) 18.70(16.30, 21.60) 19.55(17.02, 22.48) 0.002
平均动脉压(mmHg) 74.40(68.12, 83.07) 75.05(69.00, 84.00) 72.45(66.10, 79.85) < 0.001
氧分压(mmHg) 97.50(96.00, 98.80) 97.60(96.10, 98.80) 97.20(96.00, 98.80) 0.108
eGFR[ml/(min·1.73 m2)] 21.10(13.30, 48.70) 21.1(13.40, 44.92) 20.75(13.00, 54.18) 0.929
实验室指标        
红细胞(×1012/L) 3.10(2.70, 3.50) 3.10(2.70, 3.50) 3.10(2.80, 3.60) 0.210
红细胞分布宽度(%) 16.10(14.80, 17.90) 16.00(14.70, 17.40) 16.90(15.20, 19.17) < 0.001
网织红细胞(%) 2.30(1.60, 3.60) 2.30(1.60, 3.60) 2.30(1.30, 3.65) 0.410
白细胞(×109/L) 13.30(9.20, 18.50) 12.70(8.80, 17.85) 15.45(10.20, 20.08) < 0.001
中性粒细胞(×109/L) 9.87(6.47, 15.11) 9.62(6.27, 14.22) 11.6(7.46, 15.99) 0.001
淋巴细胞(×109/L) 0.94(0.56, 1.49) 0.98(0.62, 1.55) 0.84(0.50, 1.38) 0.008
单核细胞(×109/L) 0.60(0.37, 0.95) 0.58(0.36, 0.94) 0.65(0.39, 1.01) 0.128
血小板(×109/L) 156.00(102.00, 223.00) 158.00(104.00, 218.00) 151.00(97.00, 243.25) 0.827
白蛋白(g/dl) 3.00(2.50, 3.50) 3.10(2.60, 3.50) 2.90(2.30, 3.40) 0.001
尿素氮(mg/dl) 4(37, 81) 52(36, 76) 60(42, 89) < 0.001
乳酸脱氢酶(U/L) 310.00(223.00, 506.75) 296.00(215.00, 449.25) 356.50(247.75, 612.75) < 0.001
乳酸(mmol/L) 2.10(1.40, 3.90) 2.00(1.30, 3.40) 2.90(1.70, 5.10) < 0.001
血糖(mg/dl) 134.30(108.00, 174.55) 132.75(108.00, 172.22) 135.70(108.08, 184.35) 0.196
甘油三酯(mg/dl) 141.00(98.00, 248.00) 138.50(94.00, 225.00) 147(104.00, 308.50) 0.097
总胆固醇(mg/dl) 115.00(91.75, 148.00) 114.50(92.25, 150.25) 117.00(91.00, 133.50) 0.698
高密度脂蛋白胆固醇(mg/dl) 36.00(24.50, 46.00) 36(24.00, 45.00) 35.50(27.38, 47.75) 0.930
低密度脂蛋白胆固醇(mg/dl) 54.00(38.00, 72.75) 53.00(36.00, 74.50) 56.00(38.75, 71.00) 0.806
碱剩余(mEq/L) 0(－3, 3) 0(－3, 4) －1(－5, 1) < 0.001
合并症        
高血压[例(%)] 1 061(87.4) 791(88.3) 270(84.9) 0.144
心梗[例(%)] 295(24.3) 207(23.1) 88(27.7) 0.120
充血性心衰[例(%)] 589(48.5) 425(47.4) 164(51.6) 0.229
脑血管疾病[例(%)] 174(14.3) 113(12.6) 61(19.2) 0.005
慢阻肺[例(%)] 305(25.1) 215(24.0) 90(28.3) 0.148
糖尿病[例(%)] 653(53.8) 487(54.4) 166(52.2) 0.551
重度肝脏疾病[例(%)] 120(9.9) 74(8.3) 46(14.5) 0.002
肿瘤[例(%)] 123(10.1) 60(6.7) 63(19.8) < 0.001
艾滋病[例(%)] 10(0.8) 9(1.0) 1(0.3) 0.469
查尔森合并症指数 7(6, 9) 7(5, 8) 8(7, 10) < 0.001
院内诊疗操作        
透析[例(%)] 903(74.4) 687(76.7) 216(67.9) 0.003
机械通气[例(%)] 639(58.4) 439(54.9) 200(67.8) < 0.001
血管活性药物使用[例(%)] 195(16.1) 102(11.4) 93(29.2) < 0.001
疾病严重程度评分        
SAPSⅡ(分) 46(37, 55) 43(35, 52) 52(43, 63) < 0.001
SOFA评分(分) 9(6, 12) 8(6, 11) 11(8, 14) < 0.001
OASIS(分) 35.00(28.00, 41.75) 4.00(27.75, 40.00) 38.00(31.00, 44.00) < 0.001
终点指标        
住院时间(d) 11.40(6.30, 20.78) 12.80(7.10, 23.02) 7.55(3.52, 15.17) < 0.001
住ICU时间(d) 3.80(2.10, 7.30) 3.60(2.10, 7.10) 4.30(2.12, 8.17) 0.103
表2 终末期肾病合并脓毒症重症监护室内1月死亡的单因素及多因素Logistic回归分析
项目 单因素Logistic分析 多因素Logistic分析
β值 瓦尔德值 OR(95%CI) P值 β值 瓦尔德值 OR(95%CI) P值
年龄 0.04 7.08 1.04(1.03～1.05) <0.001 0.04 4.57 1.04(1.02～1.05) <0.001
心率 0.01 2.59 1.01(1.00～1.02) 0.010 0.01 1.46 1.01(1.00～1.02) 0.144
呼吸 0.05 3.39 1.06(1.02～1.09) <0.001 0.02 1.22 1.02(0.99～1.07) 0.224
平均动脉压 －0.03 －4.44 0.97(0.96～0.99) <0.001 －0.01 －1.10 0.99(0.98～1.01) 0.270
红细胞分布宽度 0.17 6.38 1.19(1.13～1.25) <0.001 0.16 5.06 1.18(1.10～1.25) <0.001
白细胞 0.03 3.84 1.03(1.01～1.04) <0.001        
中性粒细胞 0.03 3.76 1.03(1.02～1.05) <0.001 0.02 1.62 1.02(1.00～1.04) 0.106
淋巴细胞 －0.01 －0.31 0.99(0.92～1.03) 0.758        
白蛋白 －0.41 －4.18 0.66(0.55～0.80) <0.001 －0.06 －0.52 0.94(0.75～1.18) 0.602
尿素氮 0.01 3.34 1.01(1.00～1.01) <0.001 0.00 1.15 1.00(1.00～1.01) 0.252
乳酸脱氢酶 0.00 0.30 1.00(1.00～1.00) 0.766        
乳酸 0.15 6.29 1.16(1.11～1.22) <0.001 0.07 2.39 1.07(1.01～1.13) 0.017
碱剩余 －0.07 －5.72 0.93(0.91～0.95) <0.001 －0.05 －3.31 0.95(0.92～0.98) 0.001
脑血管疾病 0.50 2.85 1.64(1.16～2.31) 0.004 0.58 2.70 1.79(1.17～2.73) 0.007
重度肝脏疾病 0.63 3.15 1.88(1.26～2.77) 0.002 0.18 0.66 1.19(0.70～2.02) 0.508
肿瘤 1.24 6.37 3.44(2.35～5.04) <0.001 0.84 3.18 2.32(1.38～3.90) 0.001
查尔森合并症指数 0.23 8.60 1.25(1.19～1.32) <0.001 0.08 2.00 1.08(1.00～1.17) 0.046
透析 －0.44 －3.06 0.64(0.49～0.86) 0.002 －0.57 －3.07 0.56(0.39～0.81) 0.002
机械通气 0.57 4.18 1.76(1.35～2.30) <0.001 0.24 1.15 1.27(0.84～1.93) 0.250
血管活性药物使用 1.17 7.21 3.22(2.34～4.42) <0.001 0.35 1.57 1.41(0.92～2.18) 0.117
SAPSⅡ 0.05 9.27 1.05(1.04～1.06) <0.001 0.00 －0.50 1.00(0.98～1.01) 0.617
SOFA评分 0.16 8.73 1.17(1.13～1.22) <0.001 0.13 4.09 1.14(1.07～1.22) <0.001
OASIS 0.05 6.66 1.05(1.04～1.07) <0.001 0.01 0.63 1.01(0.98～1.04) 0.529
图2 Logistic回归预测模型的森林图
图3 联合参数模型与各评分模型受试者工作特征曲线曲线比较
表3 四种模型对终末期肾病合并脓毒症ICU住院患者预后的评估价值比较
模型 假阳性率 真阳性率 阈值 曲线下面积 置信区间下限 置信区间上限 灵敏度 特异度 约登指数
回归模型 0.24 0.69 0.28 0.79 0.76 0.82 0.69 0.76 0.45
SOFA评分 0.37 0.63 9.50 0.67 0.64 0.70 0.63 0.63 0.26
SAPSⅡ 0.20 0.48 53.50 0.68 0.64 0.71 0.48 0.80 0.27
OASIS 0.48 0.66 34.50 0.62 0.59 0.66 0.66 0.52 0.18
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