Joseph Adrien, Harel Stephanie, Venot Marion, Valade Sandrine, Mariotte Eric, Pichereau Claire, Chermak Akli, Zafrani Lara, Azoulay Elie, Canet Emmanuel
Medical Intensive Care Unit, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris and Paris Diderot University, Paris, France.
Immuno-hematology Department, Saint-Louis Hospital, Assistance Publique-Hôpitaux de Paris and Paris Diderot University, Paris, France.
Clin Kidney J. 2018 Feb;11(1):20-25. doi: 10.1093/ckj/sfx059. Epub 2017 Jul 13.
Despite substantial improvements in the management of multiple myeloma, renal failure remains an important burden that tremendously impairs prognosis. The purpose of this study was to describe the characteristics and to establish prognostic factors of renal recovery in myeloma patients admitted to the intensive care unit (ICU) for acute kidney injury (AKI) Stage 3 treated with renal replacement therapy (RRT).
A retrospective single-centre cohort study was performed, including consecutive myeloma patients admitted to one medical ICU between 1 January 2007 and 1 September 2015 and treated with RRT. Patients were evaluated 60 days after initiation of RRT and divided into three groups: alive without dialysis, alive and dialysis-dependent or deceased. A univariate analysis was performed to identify factors associated with renal recovery (alive without dialysis 60 days after initiation of RRT).
Fifty patients were included in the study. Mean age was 63 (interquartile range: 58-70) years and 32 (64%) were male. Patients were admitted to the ICU 4 (1-7) years after the diagnosis of myeloma. Twenty-one (42%) had already been treated with high-dose therapy combined with autologous stem cell transplantation. Baseline renal function evaluated by estimated glomerular filtration rate (GFR) before ICU admission was 63 (44-90) mL/min/1.73 m. The mean SOFA score at Day 1 was 7 (4-8). The three main reasons for ICU admission were AKI ( = 31, 62%), acute pulmonary oedema ( = 17, 32%) and sepsis ( = 10, 20%). During ICU stay, RRT was implemented in all patients, 16 (32%) patients required invasive mechanical ventilation and 12 (24%) received vasopressors. The mean ICU and hospital length of stay were 6 (1-7) and 28 (13-34) days, respectively. At Day 60, 23 (46%) patients were alive without dialysis, 17 (32%) had died and 10 (20%) were still undergoing dialysis. Among the 23 patients who recovered, the mean duration of dialysis was 6 (2-18) days and renal function was not significantly different from baseline [estimated GFR at baseline = 65 (25-74) mL/min/1.73 m versus 63 (56-70) mL/min/1.73 m at Day 60, P = 0.70]. By univariate analysis, two factors were associated with nonrecovery of renal function at Day 60: a history of high-dose therapy combined with autologous stem cell transplantation [odds ratio (OR) = 6.1, 95% confidence interval (CI) 1.7-21.6; P = 0.008] and a proteinuria at ICU admission >370 mg/mmol creatinine (OR = 4.2, 95% CI 1.1-17; P = 0.02). None of the other variables related to the haematological malignancy or to the ICU stay was associated with renal recovery at Day 60.
AKI Stage 3 in critically ill myeloma patients was associated with a lower than expected hospital mortality. Patients with a high level of proteinuria and a history of high-dose therapy combined with autologous stem cell transplantation were less likely to recover their renal function at Day 60.
dialysis, intensive care, multiple myeloma, prognosis, proteinuria.
尽管多发性骨髓瘤的管理有了显著改善，但肾衰竭仍然是一个重要负担，极大地影响预后。本研究的目的是描述骨髓瘤患者因急性肾损伤（AKI）3期入住重症监护病房（ICU）并接受肾脏替代治疗（RRT）后肾脏恢复的特征并确定预后因素。
进行了一项回顾性单中心队列研究，纳入2007年1月1日至2015年9月1日期间连续入住一个内科ICU并接受RRT治疗的骨髓瘤患者。在RRT开始60天后对患者进行评估，并分为三组：无需透析存活、存活且依赖透析或死亡。进行单因素分析以确定与肾脏恢复相关的因素（RRT开始60天后无需透析存活）。
本研究纳入了50例患者。平均年龄为63岁（四分位间距：58 - 70岁），男性32例（64%）。骨髓瘤诊断后4年（1 - 7年）患者入住ICU。21例（42%）患者已经接受过高剂量治疗联合自体干细胞移植。ICU入院前通过估计肾小球滤过率（GFR）评估的基线肾功能为63（44 - 90）mL/min/1.73m²。第1天的平均序贯器官衰竭评估（SOFA）评分为7分（4 - 8分）。入住ICU的三个主要原因是AKI（n = 31，62%）、急性肺水肿（n = 17，32%）和脓毒症（n = 10，20%）。在ICU住院期间，所有患者均接受了RRT，16例（32%）患者需要有创机械通气，12例（24%）患者接受了血管活性药物治疗。ICU平均住院时间和住院时间分别为6天（1 - 7天）和28天（13 - 34天）。在第60天，23例（46%）患者无需透析存活，17例（32%）患者死亡，10例（20%）患者仍在接受透析。在23例恢复患者中，平均透析时间为6天（2 - 18天），肾功能与基线无显著差异[基线时估计GFR = 65（25 - 74）mL/min/1.73m²，第60天时为63（56 - 70）mL/min/1.73m²，P = 0.70]。通过单因素分析，两个因素与第60天肾功能未恢复相关：高剂量治疗联合自体干细胞移植史[比值比（OR）= 6.1，95%置信区间（CI）1.7 - 21.6；P = 0.008]和ICU入院时蛋白尿>370mg/mmol肌酐（OR = 4.2，95%CI 1.1 - 17；P = 0.02）。与血液系统恶性肿瘤或ICU住院相关的其他变量均与第60天的肾脏恢复无关。
危重症骨髓瘤患者的AKI 3期与低于预期的医院死亡率相关。蛋白尿水平高且有高剂量治疗联合自体干细胞移植史的患者在第60天恢复肾功能的可能性较小。
透析；重症监护；多发性骨髓瘤；预后；蛋白尿
