Université paris Sud, Université Paris Saclay, Department of Anesthesiology and Critical Care, Assistance Publique-Hopitaux de Paris (AP-HP), Bicêtre Hopitaux Universitaires Paris Sud, 78 rue du Général Leclerc, 94275 Le Kremlin Bicêtre, F-94275, Le Kremlin Bicêtre, France.
Hôpitaux Universitaires Paris Nord Val de Seine, Department of Anesthesiology and Critical Care, AP-HP, Beaujon, 100 avenue du Général Leclerc, 92110, Clichy, France.
Crit Care. 2018 Dec 18;22(1):344. doi: 10.1186/s13054-018-2265-9.
Organ failure, including acute kidney injury (AKI), is the third leading cause of death after bleeding and brain injury in trauma patients. We sought to assess the prevalence, the risk factors and the impact of AKI on outcome after trauma.
We performed a retrospective analysis of prospectively collected data from a multicenter trauma registry. AKI was defined according to the risk, injury, failure, loss of kidney function and end-stage kidney disease (RIFLE) classification from serum creatinine only. Prehospital and early hospital risk factors for AKI were identified using logistic regression analysis. The predictive models were internally validated using bootstrapping resampling technique.
We included 3111 patients in the analysis. The incidence of AKI was 13% including 7% stage R, 3.7% stage I and 2.3% stage F. AKI incidence rose to 42.5% in patients presenting with hemorrhagic shock; 96% of AKI occurred within the 5 first days after trauma. In multivariate analysis, prehospital variables including minimum prehospital mean arterial pressure, maximum prehospital heart rate, secondary transfer to the trauma center and data early collected after hospital admission including injury severity score, renal trauma, blood lactate and hemorrhagic shock were independent risk factors in the models predicting AKI. The model had good discrimination with area under the receiver operating characteristic curve of 0.85 (0.82-0.88) to predict AKI stage I or F and 0.80 (0.77-0.83) to predict AKI of all stages. Rhabdomyolysis severity, assessed by the creatine kinase peak, was an additional independent risk factor for AKI when it was forced into the model (OR 1.041 (1.015-1.069) per step of 1000 U/mL, p < 0.001). AKI was independently associated with a twofold increase in ICU mortality.
AKI has an early onset and is independently associated with mortality in trauma patients. Its prevalence varies by a factor 3 according to the severity of injuries and hemorrhage. Prehospital and early hospital risk factors can provide good performance for early prediction of AKI after trauma. Hence, studies aiming to prevent AKI should target patients at high risk of AKI and investigate therapies early in the course of trauma care.
器官衰竭，包括急性肾损伤（AKI），是创伤患者继出血和颅脑损伤之后的第三大死亡原因。我们旨在评估 AKI 的发生率、危险因素以及对创伤后结局的影响。
我们对多中心创伤登记处前瞻性收集的数据进行了回顾性分析。仅根据血清肌酐采用风险、损伤、衰竭、丧失肾功能和终末期肾病（RIFLE）分级来定义 AKI。使用逻辑回归分析确定了院前和早期院内 AKI 的危险因素。使用自举重采样技术对内部分类模型进行了内部验证。
我们共纳入 3111 例患者进行分析。AKI 的发生率为 13%，其中包括 7%的 R 期、3.7%的 I 期和 2.3%的 F 期。在出现失血性休克的患者中，AKI 的发生率上升至 42.5%；96%的 AKI 发生在创伤后 5 天内。多变量分析显示，院前变量包括院前平均动脉压最低值、院前最大心率、二次转运至创伤中心以及入院后早期采集的数据（包括损伤严重程度评分、肾损伤、血乳酸和失血性休克）是预测 AKI 发生的模型中的独立危险因素。该模型对 AKI I 期或 F 期的预测具有良好的区分度，曲线下面积为 0.85（0.82-0.88），对所有阶段 AKI 的预测为 0.80（0.77-0.83）。肌红蛋白尿严重程度（肌酸激酶峰值评估）是模型中独立的 AKI 危险因素（每增加 1000 U/mL，比值比为 1.041（1.015-1.069），p<0.001）。AKI 与 ICU 死亡率增加两倍独立相关。
AKI 发病早，与创伤患者的死亡率独立相关。其发生率根据损伤和出血的严重程度而变化 3 倍。院前和早期院内危险因素可对创伤后 AKI 进行早期预测，具有良好的性能。因此，旨在预防 AKI 的研究应针对 AKI 高危患者，并在创伤治疗过程中早期研究治疗方法。
