Chawla Lakhmir S, Amdur Richard L, Faselis Charles, Li Ping, Kimmel Paul L, Palant Carlos E
1Department of Medicine, Veterans Affairs Medical Center, Washington, DC.2Division of Renal Diseases and Hypertension, Department of Medicine, George Washington University Medical Center, Washington, DC.3Department of Anesthesiology and Critical Care Medicine, George Washington University Medical Center, Washington, DC.4Department of Surgery, George Washington University Medical Center, Washington, DC.5National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD.
Crit Care Med. 2017 Apr;45(4):600-606. doi: 10.1097/CCM.0000000000002245.
Pneumonia is a common cause of hospitalization and can be complicated by the development of acute kidney injury. Acute kidney injury is associated with major adverse kidney events (death, dialysis, and durable loss of renal function [chronic kidney disease]). Because pneumonia and acute kidney injury are in part mediated by inflammation, we hypothesized that when acute kidney injury complicates pneumonia, major adverse kidney events outcomes would be exacerbated. We sought to assess the frequency of major adverse kidney events after a hospitalization for either pneumonia, acute kidney injury, or the combination of both.
We conducted a retrospective database analysis of the national Veterans Affairs database for patients with a admission diagnosis of International Classification of Diseases-9 code 584.xx (acute kidney injury) or 486.xx (pneumonia) between October 1, 1999, and December 31, 2005. Three groups of patients were created, based on the diagnosis of the index admission and serum creatinine values: 1) acute kidney injury, 2) pneumonia, and 3) pneumonia with acute kidney injury. Patients with mean baseline estimated glomerular filtration rate less than 45 mL/min/1.73 m were excluded.
The primary endpoint was major adverse kidney events defined as the composite of death, chronic dialysis, or a permanent loss of renal function after the primary discharge. The observations of 54,894 subjects were analyzed. Mean age was 68.7 ± 12.3 years. The percentage of female was 2.4, 73.3% were Caucasian, and 19.7% were African-American. Differences across the three diagnostic groups were significant for death, 25% decrease in estimated glomerular filtration rate from baseline, major adverse kidney events following admission, and major adverse kidney events during admission (all p < 0.0001). Death alone and major adverse kidney events after discharge were most common in the pneumonia + acute kidney injury group (51% died and 62% reached major adverse kidney events). In both unadjusted and adjusted time to event analyses, patients with pneumonia + acute kidney injury were most likely to die or reach major adverse kidney events.
When acute kidney injury accompanies pneumonia, postdischarge outcomes are worse than either diagnosis alone. Patients who survive a pneumonia hospitalization and develop acute kidney injury are at high risk for major adverse kidney events including death and should receive careful follow-up.
肺炎是住院治疗的常见病因，可并发急性肾损伤。急性肾损伤与严重不良肾脏事件（死亡、透析以及肾功能的永久性丧失[慢性肾脏病]）相关。由于肺炎和急性肾损伤部分由炎症介导，我们推测当急性肾损伤并发肺炎时，严重不良肾脏事件的结局会恶化。我们试图评估因肺炎、急性肾损伤或两者合并住院后严重不良肾脏事件的发生频率。
我们对1999年10月1日至2005年12月31日期间美国退伍军人事务部全国数据库中诊断为国际疾病分类第9版编码584.xx（急性肾损伤）或486.xx（肺炎）的患者进行了回顾性数据库分析。根据首次入院诊断和血清肌酐值将患者分为三组：1）急性肾损伤组，2）肺炎组，3）肺炎合并急性肾损伤组。平均基线估计肾小球滤过率低于45 mL/min/1.73 m²的患者被排除。
主要终点为严重不良肾脏事件，定义为初次出院后死亡、慢性透析或肾功能永久性丧失的复合情况。对54,894名受试者的观察数据进行了分析。平均年龄为68.7±12.3岁。女性占2.4%，73.3%为白种人，19.7%为非裔美国人。三组诊断之间在死亡、估计肾小球滤过率较基线下降25%、入院后严重不良肾脏事件以及住院期间严重不良肾脏事件方面存在显著差异（所有p<0.0001）。仅死亡以及出院后严重不良肾脏事件在肺炎+急性肾损伤组最为常见（51%死亡，62%发生严重不良肾脏事件）。在未校正和校正的事件发生时间分析中，肺炎+急性肾损伤患者最有可能死亡或发生严重不良肾脏事件。
当急性肾损伤并发肺炎时，出院后的结局比单一诊断更差。肺炎住院后存活且发生急性肾损伤的患者发生包括死亡在内的严重不良肾脏事件的风险很高，应接受密切随访。
