山东医药

目的探讨早期肾脏保护措施（ERP）执行情况与急诊重症监护病房（ICU）中急性肾损伤（AKI）患者预后的关系。方法纳入2020年1月—2023年12月中国科学技术大学附属第一医院急诊ICU收治的AKI患者，收集患者一般资料、生命体征、实验室指标及ERP执行情况等。依据KDIGO指南推荐，ERP包括避免肾毒性药物、调整药物剂量、液体复苏、监测血流动力学、监测肌酐和尿量、避免高血糖及避免对比剂7项措施。根据纳入患者执行ERP项目数的中位数将患者分为ERP良好（ERP+）或ERP不足（ERP-），比较不同ERP执行情况对急诊ICU中AKI患者AKI进展和院内死亡的影响。采用多因素Logistic回归分析ERP中7项措施对急诊ICU中AKI患者AKI进展的影响及识别患者院内死亡的独立危险因素。采用Kaplan-Meier法绘制不同AKI进展状态、不同ERP执行情况患者的生存曲线，并进行Log-Rank检验。结果共纳入AKI患者415例，执行ERP项目数的中位数为5；以此为依据，195例（47%）患者为ERP+,220例（53%）为ERP-。与ERP-患者相比，ERP+患者年龄大，心率快，血氧饱和度低，国家早期预警评分高，但AKI进展率和病死率低（P均<0.05）。7项措施中调整药物剂量措施执行最差，且ERP-患者在监测血流动力学和避免高血糖方面也执行不充分。多因素Logistic回归结果显示，未调整药物剂量、未避免肾毒性药物、未监测血流动力学及未避免对比剂均是AKI进展的独立危险因素；在校正混杂因素后，ERP-仍为患者院内死亡的独立危险因素。Kaplan-Meier生存曲线显示，AKI非进展患者生存率高于进展患者，ERP+患者的生存率高于ERP-患者（P均<0.05）。结论急诊ICU中AKI患者仅约半数接受了较完善的ERP，而ERP执行不充分可增加AKI进展和院内死亡风险；临床应强化AKI患者ERP的规范执行，以改善患者临床预后。

Objective To investigate the association between implementation of early renal protective measures(ERP) and prognosis in patients with acute kidney injury(AKI) in the emergency intensive care unit(ICU).Methods Patients with AKI admitted to the emergency ICU of the First Affiliated Hospital of the University of Science and Technology of China from January 2020 to December 2023 were included.General clinical data, vital signs, laboratory parameters, and ERP implementation were collected.According to the Kidney Disease: Improving Global Outcomes(KDIGO) guidelines, ERP included seven measures: avoidance of nephrotoxic drugs, drug dose adjustment, fluid resuscitation, hemodynamic monitoring, serum creatinine and urine output monitoring, avoidance of hyperglycemia, and avoidance of contrast agents.Patients were divided into the adequate ERP group(ERP+) and inadequate ERP group(ERP-) according to the median number of implemented ERP measures.The effects of ERP implementation on AKI progression and in-hospital mortality in emergency ICU patients with AKI were compared.Multivariable Logistic regression analysis was used to evaluate the effects of the seven ERP measures on AKI progression and to identify independent risk factors for in-hospital mortality.Kaplan-Meier survival curves were plotted according to AKI progression status and ERP implementation status, and the Log-Rank test was performed.Results A total of 415 patients with AKI were included.The median number of implemented ERP measures was 5; based on this cutoff, 195 patients were assigned to the ERP+ group(47.0%) and 220 to the ERP-group(53.0%).Compared with patients in the ERP-group, those in the ERP+ group were older, had a higher heart rate, lower oxygen saturation, and a higher National Early Warning Score(NEWS), but had lower rates of AKI progression and mortality(all P<0.05).Among the seven measures, drug dose adjustment had the poorest implementation, and hemodynamic monitoring and avoidance of hyperglycemia were also insufficiently implemented in the ERP-group.Multivariable Logistic regression analysis showed that failure to adjust drug doses, failure to avoid nephrotoxic drugs, failure to monitor hemodynamics, and failure to avoid contrast agents were independent risk factors for AKI progression.After adjustment for confounding factors, ERP-remained an independent risk factor for in-hospital mortality.Kaplan-Meier survival curves showed that the survival rate was higher in patients without AKI progression than in those with AKI progression, and higher in the ERP+ group than in the ERP-group(all P<0.05).Conclusions Only approximately half of patients with AKI in the emergency ICU receive relatively complete ERP.Inadequate implementation of ERP increases the risks of AKI progression and in-hospital mortality.Standardized implementation of ERP should be strengthened in clinical practice to improve outcomes in patients with AKI.