连续肾脏替代治疗后前两小时尿量对脓毒症合并急性肾损伤患者死亡的影响

    Effects of urinary output at 2 hours after an initiation of continuous renal replacement therapy on mortality in septic patients with acute kidney injury

      摘要
    • 摘要: 目的 基于一项回顾性队列研究的二次分析探讨连续性肾脏替代治疗（continuous renal replacement therapy，CRRT）启动后2h尿量（2-hour urinary output，UO2 h）对脓毒症合并急性肾损伤（sepsisassociated acute kidney injury，SA-AKI）患者第28天和第90天的死亡的影响。方法 本研究为一项回顾性队列数据的二次分析，原队列中连续收集了2009年1月至2016年9月韩国Health System Severance医院和Ilsan医院重症监护室中接受CRRT的SA-AKI患者。本研究采用Kaplan-Meier（K-M）生存曲线、log-rank检验、比例风险回归模型（Cox）和趋势性检验研究UO2 h对第28天和第90天死亡的独立作用，同时采用分层分析和交互作用检验进行亚组分析。最后我们通过平滑曲线拟合、分段线性模型和递归法等对UO2 h和死亡的关联关系进行了饱和阈值效应分析。结果 本研究共纳入789例接受CRRT的SA-AKI患者。K-M曲线和log-rank检验显示高UO2 h患者第28天和第90天死亡风险显著低于低UO2 h患者。Cox调整Ⅱ模型显示UO2 h与第28天和第90天死亡风险呈独立负相关（28d死亡HR=0.84，95%CI：0.75~0.94，P=0.003，90d死亡HR=0.88，95%CI：0.79~0.97，P=0.009），且两者之间存在显著线性趋势关系（趋势性检验P<0.05）。分层和交互作用检验发现白蛋白与UO2 h对第90天死亡存在显著交互作用。饱和阈值效应分析提示UO2 h与死亡之间的非线性关系是不显著的，两者之间不存在饱和阈值效应。结论 UO2 h与接受CRRT的SA-AKI患者第28天和第90天的死亡呈独立负相关，且两者之间为直线关系。

       

      Abstract: Objective Based on a secondary analysis of a retrospective cohort study, our study aimed to investigate the effects of urine output at 2-hours after initiation of continuous renal replacement therapy(CRRT)on the mortality at 28 and 90 days in sepsis patients with acute kidney injury(SAAKI). Methods This study was conducted using a retrospective cohort design, with secondary use of electronic medical records data which retrospectively collected SA-AKI patients undergoing CRRT in the ICU of Health System Severance Hospital and Ilsan Hospital in Korea from January 2009 to September 2016. Kaplan-Meier(K-M)curve, log-rank test, proportional hazard regression model(Cox)and trend test were performed to analyze the independent effects of UO2 h on mortality at 28 and 90 days. Also, stratified analysis and interaction test were conducted for subgroup analysis. Finally, we examined the possible nonlinear threshold effects of UO2 h on mortality by smooth curve fitting, piecewise linear model, recursive method et al. Results A total of 789 SA-AKI patients was included in our study. K-M curve and log-rank test found the mortality rate in patients with high UO2 h was significantly lower than that in patients with low UO2 h on 28 and 90 days. Adjusted Ⅱ Cox model revealed UO2 h was independently negatively associated with mortality at 28 and 90 days(mortality risk at 28 days:HR=0.84, 95% CI:0.75~0.94, P=0.003; mortality risk at 90 days:HR=0.88, 95% CI:0.79~0.97, P=0.009). In addition, there was a significant linear trend correlation between the two(P for trend <0.05). The stratification and interaction test indicated that serum albumin and UO2 h had a significant interaction effect on mortality at 90 days. The threshold effect analysis demonstrated that the nonlinear correlation between UO2 h and mortality was not significant and no threshold effect exist between them. Conclusions UO2 h was independently negatively correlated with mortality at 28 and 90 days in SA-AKI patients undergoing CRRT. No evidence of a non-linear relationship between them was detected.

       

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