不同标准对脓毒症急性肾损伤患者预后评估的价值

doi:10.3877/cma.j.issn.1674-1358.2016.04.011

目的

探究APACHE Ⅱ、SOFA及KDIGO共3种标准对脓毒症AKI患者的预后评估价值。

方法

搜集2013年1月至2015年1月于本院ICU接受治疗的250例脓毒症患者的临床资料，根据患者收入ICU病房的第一个24 h内的生理指标最差值，分别采用APACHE Ⅱ、SOFA评分标准对其进行评分，同时采用KDIGO标准对所有患者进行AKI诊断及分期，并用ROC曲线评估3种标准对患者预后评估的准确度，3种标准对患者预后的影响的差异则采用Logistic多元回归进行分析。

结果

250例脓毒症患者中，脓毒症肾损伤患者145例（占58%），脓毒症非肾损伤患者105例（占42%），总体院内病死率为28.6%，脓毒症肾损伤患者中Ⅰ期患者72例（占49.7%），病死率为24.3%；Ⅱ期患者44例（占30.3%），病死率为36.6%；Ⅲ期患者29例（占20.0），病死率为75.4%。与脓毒症非AKI患者相比，脓毒症肾损伤患者的APACHE Ⅱ及SOFA评分明显偏高，且差异具有统计学意义（t = 3.206，P < 0.05），Logistic多元回归分析表明，APACHEⅡ评分> 22分（OR = 4.50）及KDIGO分期中Ⅰ、Ⅱ、Ⅲ期（OR = 2.42、7.53和43.00）是预测脓毒症肾损伤患者院内死亡的独立标准。

结论

APACHE Ⅱ、SOFA及KDIGO三种标准对脓毒症肾损伤患者预后均有较好的预测价值。

关键词: 脓毒症, 急性肾损伤, 急性生理与慢性健康状况评分, 序贯器官衰竭评估

Objective

To explore the difference of the prognostic evaluation value of patients with AKI caused by sepsis in three evaluation criteria of KDIGO, APACHE Ⅱ and SOFA.

Methods

Clinical data of 250 patients with septic in department of intensive care medicine in our hospital from January 2013 to January 2015 were collected. APACHE Ⅱand SOFA scores of all patients were evaluated according to the worst value of physiologic variables in the first 24 h after ICU admission and was classified by KDIGO criteria. Discrimination and calibration of these three models were assessed by ROC curve. Besides, their effects on prognostic were evaluated by multiple Logistic regression analysis.

Results

Among the 250 admissions, 145 patients developed into AKI with the incidence of 58%. There were 105 sepsis patients with non-AKI, accounting for 42%, and the overall mortality was 29.8%. There were of 72 cases (49.7%) in phase I with the mortality rate as 24.3%; phase Ⅱof 44 patients (30.3%) with the mortality rate as 36.6%; phase Ⅲ of 29 cases (20.0%) with the mortality rate as 75.4%. APACHE Ⅱ, SOFA score of sepsis patients with AKI were significantly higher than patients with non-AKI (t = 3.206, P < 0.05). In sepsis patients with AKI, Logistic multivariate regression analysis showed that APACHE Ⅱ higher than 22 points (OR = 4.50), the KDIGO stageⅠ, Ⅱ, Ⅲ (OR = 2.42, 7.53 and 43.00) were all predictors to in-hospital deaths.

Conclusion

All the three criterias of APACHE Ⅱ, SOFA and KDIGO present good discrimination and calibration in predicting the outcome.

Key words: Sepsis, Acute kidney injury, Acute physiology and chronic health evaluation, Sequential organ failure assessment

表1 两组患者的一般资料

指征	脓毒症非AKI组（105例）	脓毒症AKI组（145例）	统计量	P值
年龄（ ±s，岁）	55.0±8.7	59.0±10.5	t = 3.190	0.002
男性[例（%）]	59（57.1）	78（53.8）	χ² = 0.276	0.599
合并慢性病[例（%）]	22（21.3）	60（41.5）	χ² = 11.529	0.001
实际病死率[例（%）]	19（18.3）	63（43.5）	χ² = 17.760	0.000
APACHE Ⅱ评分（ ±s，分）	13.8±6.6	17.3±9.6	t = 3.224	0.001
SOFA评分（ ±s，分）	5.4±3.2	7.1±4.7	t = 3.206	0.002

表1 两组患者的一般资料

指征	脓毒症非AKI组（105例）	脓毒症AKI组（145例）	统计量	P值
年龄（ ±s，岁）	55.0±8.7	59.0±10.5	t = 3.190	0.002
男性[例（%）]	59（57.1）	78（53.8）	χ² = 0.276	0.599
合并慢性病[例（%）]	22（21.3）	60（41.5）	χ² = 11.529	0.001
实际病死率[例（%）]	19（18.3）	63（43.5）	χ² = 17.760	0.000
APACHE Ⅱ评分（ ±s，分）	13.8±6.6	17.3±9.6	t = 3.224	0.001
SOFA评分（ ±s，分）	5.4±3.2	7.1±4.7	t = 3.206	0.002

表2 脓毒症AKI Ⅰ、Ⅱ、Ⅲ期患者肾功能、APACHE和SOFA评分以及院内死亡情况

项目	Ⅰ期	Ⅱ期	Ⅲ期
例数	72	44	29
基础肌酐值（ ±s，mmol/L）	68.3±36.4	71.2±25.7	95.6±58.7
最高肌酐值（ ±s，mmol/L）	131.7±52.3	233.9±97.8	413.7±186.6
实际病死率[例（%）]	11（15.9）	18（41.6）	20（68.8）
SOFA评分	4.7±3.5	8.1±6.4	9.3±3.8
APACHE Ⅱ评分	15.7±7.7	18.6±7.8	22.3±3.4

表2 脓毒症AKI Ⅰ、Ⅱ、Ⅲ期患者肾功能、APACHE和SOFA评分以及院内死亡情况

项目	Ⅰ期	Ⅱ期	Ⅲ期
例数	72	44	29
基础肌酐值（ ±s，mmol/L）	68.3±36.4	71.2±25.7	95.6±58.7
最高肌酐值（ ±s，mmol/L）	131.7±52.3	233.9±97.8	413.7±186.6
实际病死率[例（%）]	11（15.9）	18（41.6）	20（68.8）
SOFA评分	4.7±3.5	8.1±6.4	9.3±3.8
APACHE Ⅱ评分	15.7±7.7	18.6±7.8	22.3±3.4

表3 APACHE Ⅱ、SOFA评分系统及KDIGO分期系统对脓毒症AKI患者院内病死率影响的Logistic多元回归分析

项目	Beta值	S.E.值	Wald值	OR值	95%CI值	P值
APACHE Ⅱ评分	1.447	0.461	9.852	4.250	1.722～10.491	0.002
SOFA评分	0.429	1.201	0.128	1.536	0.146～16.167	0.720
KDIGO Ⅰ期	0.775	0.263	8.683	2.171	1.296～3.635	0.003
KDIGO Ⅱ期	2.083	0.674	9.551	8.029	2.142～30.085	0.000
KDIGO Ⅲ期	3.723	1.095	11.560	41.388	4.839～353.966	0.001

表3 APACHE Ⅱ、SOFA评分系统及KDIGO分期系统对脓毒症AKI患者院内病死率影响的Logistic多元回归分析

项目	Beta值	S.E.值	Wald值	OR值	95%CI值	P值
APACHE Ⅱ评分	1.447	0.461	9.852	4.250	1.722～10.491	0.002
SOFA评分	0.429	1.201	0.128	1.536	0.146～16.167	0.720
KDIGO Ⅰ期	0.775	0.263	8.683	2.171	1.296～3.635	0.003
KDIGO Ⅱ期	2.083	0.674	9.551	8.029	2.142～30.085	0.000
KDIGO Ⅲ期	3.723	1.095	11.560	41.388	4.839～353.966	0.001

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The value of different criteria in assessing the prognostic evaluation of patients with AKI caused by sepsis

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The value of different criteria in assessing the prognostic evaluation of patients with AKI caused by sepsis