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中华损伤与修复杂志(电子版) ›› 2024, Vol. 19 ›› Issue (04) : 282 -287. doi: 10.3877/cma.j.issn.1673-9450.2024.04.002

论著

大面积烧伤患者发生早期急性肾损伤的危险因素分析
张锦丽1, 席毛毛1, 褚志刚1, 栾夏刚1, 陈诺1, 王德运1,†(), 谢卫国1   
  1. 1. 430060　武汉大学同仁医院暨武汉市第三医院烧伤科
  • 收稿日期:2023-12-18 出版日期:2024-08-01
  • 通信作者: 王德运
  • 基金资助:
    武汉市卫健委科研项目(WG19B02)

Analysis of risk factors of early acute kidney injury in patients with massive burn injuries

Jinli Zhang1, Maomao Xi1, Zhigang Chu1, Xiagang Luan1, Nuo Chen1, Deyun Wang1,†(), Weiguo Xie1   

  1. 1. Department of Burns, Tongren Hospital of Wuhan University & Wuhan Third Hospital, Wuhan 430060, China
  • Received:2023-12-18 Published:2024-08-01
  • Corresponding author: Deyun Wang
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引用本文：

张锦丽, 席毛毛, 褚志刚, 栾夏刚, 陈诺, 王德运, 谢卫国. 大面积烧伤患者发生早期急性肾损伤的危险因素分析[J]. 中华损伤与修复杂志(电子版), 2024, 19(04): 282-287.

Jinli Zhang, Maomao Xi, Zhigang Chu, Xiagang Luan, Nuo Chen, Deyun Wang, Weiguo Xie. Analysis of risk factors of early acute kidney injury in patients with massive burn injuries[J]. Chinese Journal of Injury Repair and Wound Healing(Electronic Edition), 2024, 19(04): 282-287.

目的

探讨大面积烧伤患者发生早期急性肾损伤(AKI)的危险因素，为临床治疗提供参考。

方法

选择2018年1月至2022年8月武汉大学同仁医院暨武汉市第三医院烧伤科收治的符合入选标准的201例成年大面积烧伤患者，其中男137例，女64例，年龄49(36，56)岁，烧伤总面积为70%(59.5%，85%)体表总面积，简明烧伤严重度指数(ABSI)评分49(37.5，62.9)分。根据伤后3 d内是否发生AKI将患者分为AKI组和非AKI组。采用单因素分析筛选可能影响AKI发生的相关因素，包括性别、年龄、致伤原因、基础疾病、伤后至入院时间、基础伤情、治疗情况等指标。数据分析采用两独立样本t检验、Mann-Whitney U检验、χ2检验或Fisher确切概率法。结合单因素分析结果及临床意义，将指标纳入自变量，进行多因素Logistic回归分析，筛选出大面积烧伤患者发生早期AKI的独立危险因素，建立预测模型并计算模型的ROC曲线下面积。

结果

共71例(35.3%)患者在伤后3 d内发生AKI。与非AKI组相比，AKI组患者年龄更大(P＝0.013)，男性(P＝0.002)、电烧伤(P<0.001)、高血压(P＝0.007)、吸入性损伤(P＝0.010)的百分比更高，烧伤总面积(P<0.001)、Ⅲ度烧伤面积(P<0.001)更大，ABSI评分更高(P<0.001)，首次手术出血量更大(P＝0.002)，且切开减张(P<0.001)、气管切开(P<0.001)、机械通气(P<0.001)的百分比更高，入院时部分化验指标(包括尿素氮、肌酐、胱抑素C、乳酸、红细胞压积、血小板总数)更高(P<0.05)，伤后3 d内去甲肾上腺素(P＝0.019)、呋塞米(P<0.001)用药百分比更高。根据单因素分析结果及变量的临床意义，筛选出10个可能的影响因素为自变量，进行Logistic回归分析，结果显示性别、年龄、电烧伤、ABSI评分、气管切开、入院时血乳酸值是大面积烧伤患者发生早期AKI的独立危险因素。经多因素Logistic回归分析建立大面积烧伤患者发生早期AKI的预测模型，方程为Logit(P)＝-7.021＋1.339×男性＋0.047×年龄＋1.990×电烧伤＋1.543×ABSI评分＋1.475×气管切开＋0.185×入院时血乳酸值，该模型的ROC曲线下面积为0.855(95%CI：0.800～0.910，P<0.001)，灵敏度为0.823，特异度为0.737。

结论

男性、年龄偏大、电烧伤、ABSI评分偏高、气管切开、入院时血乳酸值偏高的大面积烧伤患者发生早期AKI的可能性更大。

关键词: 烧伤, 急性肾损伤, 危险因素, 回顾性研究
Objective

To explore the risk factors of early acute kidney injury (AKI) in patients with massive burn injuries and provide reference for clinical treatment.

Methods

A total of 201 adult inpatients with massive burn injuries who met the inclusion criteria in Department of Burns, Tongren Hospital of Wuhan University & Wuhan Third Hospital from January 2018 to August 2022 were entrolled, including 137 males and 64 females, aged 49 (36, 56) years old, the total burn area was 70% (59.5%, 85%) of the total body surface area(TBSA), and abbreviated burn severity index (ABSI) score was 49 (37.5, 62.9). The patients were divided into AKI group and non-AKI group according to whether AKI occurred within 3 days after injury. Univariate analysis was used to screen the factors that might affect the occurrence of AKI, including gender, age, cause of injury, basic diseases, the time from injury to admission, features of basic injuries, and treatment. Data were statistically analyzed with independent sample t test, Mann-Whitney U test, chi-square test or Fisher exact probability method. The multivariate Logistic regression analysis was conducted to screen the independent risk factors for early AKI in patients with massive burn injuries, and the inclusion of factors combined with univariate analysis results and clinical significance. A prediction model was established by the outcome of multivariate Logistic regression and the area under the ROC curve of the model was calculated.

Results

AKI occurred in 71 patients (35.3%) within 3 days after injury. In comparison to the non-AKI group, the AKI group had the older age(P=0.013), higher percentage of males(P=0.002), electric burns(P<0.001), hypertension(P=0.007), and inhalation injury(P=0.010), larger total burn area (P<0.001) and full-thickness burn area(P<0.001), higher ABSI score (P<0.001), more blood lost in the first operation (P=0.002), higher percentage of incision and tension reduction of burn eschar (P<0.001), tracheotomy (P<0.001) and mechanical ventilation(P<0.001); the AKI group had higher value of some serum parameters on admission, including urea nitrogen, creatinine, cystatin C, lactate, hematocrit, and total platelet count (P<0.05); the AKI group had higher usage rate of norepinephrine (P=0.019), and furosemide (P<0.001) injection within 3 days after injury.According to the results of univariate analysis and the clinical significance of the variables, 10 possible predictive variables were screened out and multivariate Logistic regression analysis was performed. The results showed that gender, age, electric burn, ABSI score, tracheotomy, and lactate on admission were independent risk factors for early AKI in patients with massive burn injuries. The predictive model for early AKI in massive burn patients was established through multivariate Logistic regression analysis: Logit (P)=-7.021+ 1.339 × male+ 0.047 × age+ 1.990 × electric burns+ 1.543 × ABSI score + 1.475 × tracheotomy+ 0.185 × lactate value on admission, and the area under the ROC curve of the model was 0.855 (95% CI: 0.800~0.910, P<0.001), with sensitivity and specificity of 0.823 and 0.737, respectively.

Conclusion

The elderly male massive burn patients with electric burn, high ABSI score, tracheotomy, and high lactate on admission are more likely to occur early AKI.

Key words: Burns, Acute kidney injury, Risk factors, Retrospective studies
表1 AKI组与非AKI组大面积烧伤患者一般情况比较
指标 AKI组(n＝71) 非AKI组(n＝130) χ2/Z/t值 P值
性别[例(%)]     9.261 0.002
男 58(81.7) 79(60.8)    
女 13(18.3) 51(39.2)    
年龄[岁，M(P25，P75)] 50 (40，60) 48(33.8，54.3) 2.485 0.013
电烧伤[例(%)] 13(18.3) 4(3.1) 13.763 <0.001
高血压[例(%)] 18(25.4) 14(10.8) 7.295 0.007
糖尿病[例(%)] 6(8.5) 11(8.5) <0.001 0.998
吸入性损伤[例(%)] 43(60.6) 54(41.5) 6.656 0.010
伤后至入院时间[h，M(P25，P75)] 3(2，4) 3(2，4) 0.621 0.535
烧伤总面积[%TBSA，M(P25，P75)] 80(60，90) 65(55，78) 3.763 <0.001
Ⅲ度烧伤面积[%TBSA，M(P25，P75)] 42(19，61) 25(12.8，41) 3.927 <0.001
ABSI评分[分，M(P25，P75)] 63.1(40.9，72.5) 45.3(36.0，56.3) 3.983 <0.001
入院后24 h补液量[mL·kg-1·%TBSA-1，±s] 2.2±0.8 2.1±0.9 0.302 0.763
入院后48 h补液量[mL·kg-1·%TBSA-1，M(P25，P75)] 4.0(3.4，4.8) 3.8(3.1，4.4) 1.394 0.163
切开减张[例(%)] 16(22.5) 4(3.1) 19.404 <0.001
首次手术时间[d，M(P25，P75)] 4(2，5) 3(2，4) 1.872 0.061
首次手术切痂面积[%TBSA，M(P25，P75)] 38(25，45) 40(30，45) 0.020 0.984
首次手术出血量[mL，M(P25，P75)] 400(100，525) 200(100，400) 3.156 0.002
首次手术输液量(mL，±s) 2285.7±898.5 2279.1±888.6 0.047 0.962
住院天数[d，M(P25，P75)] 48(23，87) 49(28，77) 0.315 0.753
气管切开[例(%)] 65(91.5) 74(56.9) 25.811 <0.001
机械通气[例(%)] 49(69.0) 47(36.2) 19.874 <0.001
表2 AKI组与非AKI组大面积烧伤患者入院时化验指标比较
指标 AKI组(n＝71) 非AKI组(n＝130) Z值 P值
白蛋白[g/L，M(P25，P75)] 34.2 (28.2，39.0) 34.6 (30.0，39.9) 1.085 0.278
尿素氮[mmol/L，M(P25，P75)] 6.8 (6.1，8.5) 6.0 (4.8，7.0) 4.459 <0.001
肌酐[μmol/L，M(P25，P75)] 101.8 (84.7，124.0) 66.9 (57.4，79.0) 8.649 <0.001
胱抑素C[mg/L，M(P25，P75)] 0.8 (0.6，1.0) 0.6 (0.5，0.8) 3.745 <0.001
乳酸[mmol/L，M(P25，P75)] 7.8 (6.6，9.9) 5.7 (4.2，7.9) 5.061 <0.001
红细胞压积[%，M(P25，P75)] 50.6 (46.5，56.0) 48.8 (45.1，51.6) 2.093 0.036
血小板总数[×109/L，M(P25，P75)] 279 (212.3，386.0) 229 (168.3，275.4) 4.126 <0.001
表3 AKI组与非AKI组大面积烧伤患者伤后3 d内用药情况比较[例(%)]
指标 AKI组(n＝71) 非AKI组(n＝130) χ2值 P值
去甲肾上腺素 8 (11.3) 3 (2.3) 5.499 0.019
呋塞米 51 (71.8) 51 (39.2) 19.526 <0.001
头孢类 22 (31.0) 54 (41.5) 2.175 0.140
阿米卡星 50 (70.4) 86(66.2) 0.382 0.536
替加环素 5 (7.0) 2 (1.5) 2.663 0.103
地塞米松 70 (98.6) 120 (92.3) 2.396 0.122
比阿培南 32(45.1) 52 (40.0) 0.485 0.486
万古霉素 0(0) 1(0.8) - 1.000
图1 大面积烧伤患者发生早期AKI多因素分析预测模型的ROC曲线
表4 大面积烧伤早期AKI的多因素Logistic回归分析
因素 β值 OR值 95%CI P值
性别(男性) 1.339 3.816 1.268～11.483 0.017
年龄 0.047 1.048 1.008～1.090 0.018
电烧伤 1.990 7.317 1.105～48.468 0.039
ABSI评分大于63分 1.543 4.680 1.679～13.047 0.003
气管切开 1.475 4.371 1.193～16.006 0.026
入院时血乳酸值 0.185 1.203 0.997～1.451 0.050
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