住院患者急性肾损伤临床预后评分系统的建立及初步评估

摘要

目的 明确住院患者急性肾损伤(acute kidney injury,AKI)的危险因素,并建立AKI预后评分系统.方法 入组上海市复旦大学附属华山医院2009年1月到2011年9月发生AKI的成人患者261例,构成试验组；2011年10月到2012年3月院内AKI的成人患者102例,构成验证组,分别随访90天,同时统计90天的死亡率.应用多因素Logistic回归分析确定AKI 90天死亡的独立危险因素,并根据其OR值赋予相应积分,形成评分系统,同时建立AKI 90天死亡率的预测曲线图.计算试验组和验证组各病例的总积分,比较不同得分组AKI死亡率.用ROC曲线和Hosmer-Lemeshow法评价该评分系统的效能. 结果 ①经多因素Logistic回归分析确定与AKI 90天预后相关的5个独立危险因素:并发症数目,使用血管活性物质(多巴胺),机械通气,尿素氮、前白蛋白;②试验组病例依据危险因素积分总和得出评分系统:总评分≤4分(低危组)AKI死亡率为16.8％；5～l0分(中危组)死亡率为48.0％; 11～16分(高危组)为76.0％; 17～30分(极高危组)100％.ROC曲线下面积为0.801(P＜0.001);③经验证组证实,AKI总积分与其死亡率密切相关,该预后评分系统具有良好的预测能力(x2=4.149,P=0.657). 结论 该AKI预后评分系统可较为准确预测AKI 90天死亡率,为改善院内AKI患者的预后提供依据.%Objective This study was designed to establish a clinical prediction score for the prognosis of acute kidney injury (AKI) in hospitalized patients. Methods A total of 363 hospitalized AKI patients in Huashan Hospital from January 2011 to March 2012 were enrolled. In this prospective cohort study, the 261 AKI patients were assigned as the test group, and the 102 AKI patients as the validation group. Multivariate logistic regression analysis was applied to identify the risk factors for AKI. Based on the odds ratios, we derived a new prediction score system, from which the prediction curve for AKI mortality within 90 days was established. The ROC curve and Hosmer-Lemeshow goodness-of-fit chi-squared test were used to assess the accuracy and efficacy of the scoring system. Results ①Five variables were identified as the independent risk factors for AKI, including total number of complications, vasopressor (dopamine) support, mechanical ventilation, blood urea nitrogen (BUN), and serum prealbumin. ②The overall risk score was calculated from the scores of risk factors for each patient in the test group. The incidence of AKI was 16.8% in the low-risk subgroup (=4 points), 48.0% in the moderate-risk subgroups (5~10 points), 76.0% in the high-risk subgroup (11 ~ 16 points) and 100% in the very-high-risk subgroup (17~30 points). The area under the ROC curve was 0.801 (P < 0.001). (3) Good discriminative power was found in the validation group, and the risk score was strongly correlated with AKI mortality (χ2=4.149, P=0.657). Conclusion This scoring system can accurately predict the mortality of AKI patients developed during hospitalization. Clinical application of this score may be useful for the decision of kidney protection interventions and the improvement of prognosis in AKI patients developed in hospital.