Division of Trauma, Burns, & Surgical Critical Care, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida.
Division of Trauma, Burns, & Surgical Critical Care, Daughtry Family Department of Surgery, University of Miami Miller School of Medicine and Ryder Trauma Center, Miami, Florida.
J Surg Res. 2019 Dec;244:477-483. doi: 10.1016/j.jss.2019.06.087. Epub 2019 Jul 19.
Augmented renal clearance (ARC; i.e., creatinine clearance [CL] ≥ 130 mL/min) has an incidence of 14%-80% in critically ill patients and has been associated with therapy failures for renally cleared drugs. However, the clinical implications of ARC are poorly defined. We hypothesize that modifiable risk factors that contribute to ARC can be identified in severely injured trauma patients and that these risk factors influence clinical outcome.
In 207 trauma intensive care unit patients, 24-h CL was correlated with clinical estimates of glomerular filtration rate (by Cockroft-Gault, modification of diet in renal disease, or chronic kidney disease epidemiology), and clinical outcomes (infection, venous thromboembolism [VTE], length of stay, and mortality).
The population was 45 ± 20 y, 68% male, 77% blunt injury with injury severity score of 24 (17-30). Admission serum creatinine was 1.02 ± 0.35 mg/dL, CL was 154 ± 77 mL/min, VTE incidence was 15%, ARC incidence was 57%, and mortality was 11%. Clinical estimates of glomerular filtration rate by Cockroft-Gault, modification of diet in renal disease, chronic kidney disease epidemiology underestimated actual CL by 20%, 22%, or 15% (all P < 0.01). CL was higher in males and those who survived, and lower in those with hypertension, diabetes, positive cultures, receiving transfusions, or pressors (all P < 0.05). On multivariate analysis, male gender (odds ratio [OR] 2.9 [1.4-6.1]), age (OR 0.97 [0.95-0.99]), and packed red blood cells transfusion (OR 0.31 [0.15-0.66]) were the only independent predictors of ARC.
ARC occurs in more than half of all high-risk trauma intensive care unit patients and is underestimated by standard clinical equations. ARC was not associated with increased incidence of VTE or infection but rather is associated with younger healthier males and reduced mortality. ARC seems to be a beneficial compensatory response to trauma.
急性肾损伤（ARC；即肌酐清除率[CL]≥130mL/min）在重症患者中的发生率为 14%-80%，并与经肾脏清除的药物治疗失败有关。然而，ARC 的临床意义尚未明确。我们假设在严重创伤患者中可以确定导致 ARC 的可改变的危险因素，并且这些危险因素会影响临床结果。
在 207 例创伤重症监护病房患者中，将 24 小时 CL 与肾小球滤过率的临床估计值（通过 Cockroft-Gault、改良肾脏病饮食法或慢性肾脏病流行病学公式）以及临床结果（感染、静脉血栓栓塞[VTE]、住院时间和死亡率）进行相关性分析。
该人群的平均年龄为 45±20 岁，68%为男性，77%为钝性损伤，损伤严重程度评分 24（17-30）。入院时血清肌酐为 1.02±0.35mg/dL，CL 为 154±77mL/min，VTE 发生率为 15%，ARC 发生率为 57%，死亡率为 11%。Cockroft-Gault、改良肾脏病饮食法或慢性肾脏病流行病学公式对肾小球滤过率的临床估计值分别低估了实际 CL 20%、22%或 15%（均 P<0.01）。CL 在男性和存活患者中较高，而在高血压、糖尿病、阳性培养物、输血或升压药患者中较低（均 P<0.05）。多变量分析显示，男性（比值比[OR]2.9[1.4-6.1]）、年龄（OR 0.97[0.95-0.99]）和浓缩红细胞输血（OR 0.31[0.15-0.66]）是 ARC 的唯一独立预测因素。
ARC 发生在超过一半的高危创伤重症监护病房患者中，且被标准临床公式低估。ARC 与 VTE 或感染的发生率增加无关，而是与年轻、健康的男性和较低的死亡率相关。ARC 似乎是对创伤的有益代偿反应。
