不同病原菌致血流感染相关急性肾损伤的危险因素分析

doi:10.16138/j.1673-6087.2021.01.006

摘要/Abstract

摘要：

目的：研究不同病原菌所致血流感染患者中急性肾损伤(acute kidney injury, AKI)的发生率、危险因素和预后。方法：2018年1月1日至12月31日我院血流感染患者,选取最常见的4种病原体肺炎克雷伯菌、大肠埃希菌、凝固酶阴性葡萄球菌和金黄色葡萄球菌共计348例患者纳入本研究。收集患者基本资料、住院期间生化指标及血培养阳性前有创操作的时间和类型。根据改善全球肾脏病预后组织（Kidney Disease: Improving Global Outcomes,KDIGO）AKI诊断标准,AKI定义为48 h内肌酐升高≥26.5 μmol/L或1周内肌酐水平增加超过基线肌酐水平的1.5倍。Logistic回归分析用于分析不同病原菌所致血流感染患者发生AKI的危险因素和发生率及预后。结果：348例患者中70例发生AKI,发生率为20.1%。AKI的发生率金黄色葡萄球菌感染为23.3%、凝固酶阴性葡萄球菌感染为22.2%、肺炎克雷伯菌为22.0%、大肠埃希菌为15.1%。与未发生AKI的患者相比,发生AKI的患者基础肌酐为（80.01±37.09） μmol/L,显著高于未发生AKI者[（69.98±46.40） μmol/L]（P=0.008）,并且发生AKI组患者接受的有创操作更多（70.0%比34.5%,P=0.001）。多因素Logistic回归分析显示,不同病原菌所致血流感染的AKI患者中,有创操作是危险因素[优势比（odds ratio,OR）=3.25, 95%置信区间（confidence interval,CI）：1.80~5.89, P<0.001]。不同病原菌血流感染中AKI发生率（ χ²=2.42,P=0.49）、肾功能恢复（χ²=6.40,P=0.09）、死亡（ χ²=2.40,P=0.49）差异均无统计学意义。结论：有创操作是不同病原菌所致血流感染患者发生AKI的危险因素,不同病原菌血流感染后AKI发生率和预后差异无统计学意义。

关键词: 病原菌, 血流感染, 急性肾损伤, 肌酐, 脓毒症

Abstract:

Objective To investigate the incidence, risk factors and prognosis of acute kidney injury(AKI) in the patients with bloodstream infection caused by different pathogens. Methods From January 1, 2018 to December 31, 2018, the patients with blood stream infection in our hospital were enrolled and four most common pathogens including Klebsiella pneumoniae, Escherichia coli, coagulase-negative Staphylococcus and Staphylococcus aureus were tested and total 348 patients were included in this study. The basic information, biochemical indicators during hospitalization and the time and type of invasive procedures before positive blood culture of patients were collected. In accordance with Kidney Disease: Improving Global Outcomes(KDIGO) AKI diagnostic criteria, the definition of AKI was an creatinine increase ≥26.5 μmol/L within 48 h or an 1.5 time increase than the baseline creatinine level within 1 week. The Logistic regression analysis was used to analyze the risk factors, incidence, and prognosis of AKI in the patients with bloodstream infection caused by different pathogens. Results A total of 348 patients with positive blood culture were included in this study. Among them, 70 patients (20.1%) developed AKI. The incidence of AKI was 23.3%, 22.2%, 22% and 15.1% in the patients infected with Staphylococcus aureus, coagulase negative Staphylococcus, Klebsiella pneumoniae and Escherichia coli, respectively. The basic creatinine in the patients with AKI was (80.01±37.09) μmol/L, which was significantly higher than that in the cases without AKI [(69.98±46.40) μmol/L, P=0.008], and the patients in the AKI group received more invasive procedures (70.0% vs 34.5%, P=0.001). Multivariate Logistic regression analysis showed that the invasive procedures were risk factors for AKI patients with bloodstream infection caused by different pathogens [odds ratio(OR)=3.25, 95% confidence interval (CI): 1.80-5.89, P<0.001]. The incidence of AKI (χ²=2.42, P=0.49), kidney function recovery (χ²=6.40, P=0.09) and mortality (χ²=2.40, P=0.49) in bloodstream infection caused by different pathogens didn’t show statistical difference. Conclusions The invasive procedures are risk factors for AKI in the patients with bloodstream infection caused by different pathogens. There is no statistical difference in the incidence and prognosis of AKI among the patients with bloodstream infection caused by different pathogens.

Key words: Pathogen, Bloodstream infection, Acute kidney injury, Creatinine, Sepsis

中图分类号:

R692

王雪洁, 陈孜瑾, 杜雯, 顾飞飞, 俞海瑾, 张文, 陈晓农. 不同病原菌致血流感染相关急性肾损伤的危险因素分析[J]. 内科理论与实践, 2021, 16(01): 22-26.

WANG Xuejie, CHEN Zijin, DU Wen, GU Feifei, YU Haijin, ZHANG Wen, CHEN Xiaonong. Risk factors of acute kidney injury in the patients with bloodstream infection caused by different pathogens[J]. Journal of Internal Medicine Concepts & Practice, 2021, 16(01): 22-26.

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项目	金黄色葡萄球菌(n=43)	肺炎克雷伯菌(n=118)	大肠埃希菌(n=106)	凝固酶阴性葡萄球菌(n=81)
男性[n(%)]	33(76.7)	77(65.3)	68(64.2)	53(65.4)
高血压[n(%)]	17(39.5)	49(41.5)	38(35.8)	40(49.4)
糖尿病[n(%)]	9(20.9)	27(22.9)	25(23.6)	29(35.8)
有创操作[n(%)]	26(60.5)	75(63.6)	42(39.6)	39(48.1)
年龄(岁)	60.51±19.78	56.72±16.89	61.55±17.45	59.53±17.30
血红蛋白(g/L)	118.23±28.19	118.60±35.19	114.49±27.61	117.22±26.40
白蛋白(g/L)	33.44±7.30	33.31±6.73	34.22±7.22	35.84±6.79
肌酐(μmol/L)	70.49±37.00	67.94±46.40	70.13±37.00	72.57±45.10
eGFR[mL/(min·1.73m²)]	92.28±30.02	86.73±32.25	86.85±29.79	80.18±28.24
尿酸(μmol/L)	319.58±136.60	299.09±140.48	303.11±120.82	362.02±146.78
尿素(mmol/L)	6.98±3.98	7.26±5.10	6.61±4.58	7.98±6.00

指标	AKI (n=70)	非AKI(n=278)	t/χ²	P
男性[n(%)]	52(74.3)	179(54.6)	3.506	0.061
年龄(岁)	62.63±13.62	58.49±18.63	1.977	0.048
高血压[n(%)]	31(44.3)	143(51.4)	1.001	0.317
糖尿病[n(%)]	22(31.4)	68(24.5)	0.343	0.558
有创操作[n(%)]	49(70.0)	96(34.5)	17.832	0.001
病原菌种类
金黄色葡萄球菌[n(%)]	10(23.3)	33(76.7)	3.501	0.583
凝固酶阴性葡萄球菌[n(%)]	18 (22.2)	63 (77.8)	1.713	0.589
肺炎克雷伯菌[n(%)]	26 (22.0)	92 (78.0)	2.295	0.522
大肠埃希菌[n(%)]	16(15.1)	90(84.9)	0.003	0.122
血红蛋白(g/L)	119.13±27.10	116.89±30.63	0.530	0.597
白蛋白(g/L)	33.93±6.45	34.44±7.13	0.538	0.538
肌酐(μmol/L)	80.01±37.09	69.98±46.40	1.736	0.008
eGFR[mL/(min·1.73m²)]	80.05±27.82	87.76±30.98	1.796	0.557
尿酸(μmol/L)	345.79±144.62	306.23±134.44	2.055	0.487
尿素(mmol/L)	7.30±3.84	6.95±4.92	0.521	0.521

变量	单因素分析		多因素分析
变量	OR (95% CI)	P	OR (95% CI)	P
年龄（岁）	1.01(1.00~1.03)	0.10	1.02(1.00~1.04)	0.10
女性	0.55(0.29~1.04)	0.06	1.68 (0.87~3.27)	0.12
血红蛋白	1.00(0.99~1.01)	0.60	-	-
白蛋白	0.99(0.95~1.03)	0.59	-	-
GFR	0.99(0.98~1.00)	0.07	1.00(0.99~1.02)	0.77
尿酸	1.00(1.00~1.00)	0.04	1.00(1.00~1.00)	0.16
尿素	1.02(0.96~1.07)	0.60	-	-
合并基础疾病	1.21(0.84~1.76)	0.31	-	-
接受有创操作	3.34(1.88~5.96)	<0.01	3.25(1.80~5.89)	<0.01
病原菌种类	1.189(0.93~1.516)	0.17	-	-
大肠埃希菌	-	-		-
金黄色葡萄球菌	-	-	0.99(0.35~2.78)^*	0.98
肺炎克雷伯菌	-	-	1.33(0.46~2.89)^*	0.46
凝固酶阴性葡萄球菌	-	-	1.64(0.72~3.70)^*	0.24