摘要
目的探讨两性霉素B脱氧胆酸盐使用后发生急性肾损伤(acute kidney injury,AKI)的危险因素及构建预测模型以指导临床监测与干预。方法采用回顾性分析,纳入2014年1月至2024年9月使用两性霉素B脱氧胆酸盐的住院患者,分为训练集和验证集。提取患者一般资料、实验室检查结果和药品医嘱,根据用药期间及停药后7 d内是否发生AKI,将患者分为AKI组与非AKI组。通过单因素分析筛选潜在危险因素,采用多因素Logistic回归构建预测模型,并通过受试者操作特征曲线下面积和Hosmer-Lemeshow检验评估模型性能。结果训练集共纳入473例患者,其中男性255例(53.91%)、女性218例(46.09%),中位年龄为52(35,62)岁,AKI组191例(40.38%)、非AKI组282例(59.62%);验证集共纳入114例患者,其中男性80例(70.18%)、女性34例(29.82%),中位年龄为43.5(31.0,58.5)岁,AKI组42例(36.84%)、非AKI组72例(63.16%)。单因素分析显示两组患者一般资料(年龄、进入重症监护室治疗、死亡、住院时间)、实验室检查结果(血肌酐高于正常值、尿素高于正常值、中性粒细胞百分比低于正常值、中性粒细胞百分比高于正常值、淋巴细胞百分比低于正常值、血钠高于正常值)、合并用药(非甾体抗炎药、抗真菌药物、神经系统药物、肾上腺素类药物、碳酸氢钠片/注射液、苯海拉明/异丙嗪注射液、非甾体抗炎药+苯海拉明/异丙嗪、非甾体抗炎药+糖皮质激素、苯海拉明/异丙嗪+糖皮质激素、非甾体抗炎药+苯海拉明/异丙嗪+糖皮质激素)、合并症(糖尿病、肾病、心功能不全)共23个因素差异具有统计学意义(P均<0.05)。多因素分析显示,进入重症监护室治疗(OR=2.128,95%CI:1.415~3.201)、入院血肌酐高于正常值(OR=1.920,95%CI:1.235~2.985)、合并心功能不全(OR=3.394,95%CI:1.369~8.417)为危险因素,而预防性使用苯海拉明/异丙嗪注射液(OR=0.182,95%CI:0.083~0.399)或碳酸氢钠片/注射液(OR=0.512,95%CI:0.339~0.773)为保护因素。预测模型方程式为:logit(P)=ln[P/(1-P)]=-0.479+0.755X_(s_(1))+0.652X_(2)+1.222X_(3)-1.702X_(4)-0.67X_(5)(X_(1)为进入重症监护室治疗,X_(2)为入院血肌酐高于正常值,X_(3)为合并心功能不全,X_(4)为合并使用苯海拉明/异丙嗪注射液,X_(5)为合并使用碳酸氢钠片/注射液,X根据是否满足条件取值“1”或者“0”)。该模型在训练集和验证集的AUC分别为0.735(95%CI:0.691~0.780)和0.699(95%CI:0.604~0.795),Hosmer-Lemeshow检验显示,χ^(2)值为4.048,P=0.774,提示模型校准度良好。结论进入重症监护室治疗、入院血肌酐升高以及合并心功能不全是AKI发生的潜在危险因素,而预防性使用苯海拉明/异丙嗪或碳酸氢钠则表现出保护性关联,所构建的预测模型具有良好区分度和校准度,可为临床早期识别高危患者以及治疗方案的及时调整提供参考。
Objective To investigate the risk factors for acute kidney injury(AKI)following the use of amphotericin B deoxycholate and to develop a predictive model to guide clinical monitoring and intervention.Methods A retrospective analysis was conducted on hospitalized patients who received amphotericin B deoxycholate between January 2014 and September 2024.Patients were divided into a training set and a validation set.Demographic data,laboratory findings,and medication orders were collected.Based on the occurrence of AKI during treatment and within 7 days after discontinuation,patients were classified into an AKI group and a non-AKI group.Univariate analysis was used to screen for potential risk factors,multivariate logistic regression was employed to construct a predictive model,and model performance was evaluated using the area under the receiver operating characteristic curve(AUC)and the Hosmer-Lemeshow test.Results The training set included 473 patients,comprising 255 males(53.91%)and 218 females(46.09%),with a median age of 52(35,62)years.The AKI group consisted of 191 cases(40.38%),and the non-AKI group consisted of 282 cases(59.62%).The validation set included 114 patients,comprising 80 males(70.18%)and 34 females(29.82%),with a median age of 43.5(31.0,58.5)years.The AKI group consisted of 42 cases(36.84%),and the non-AKI group consisted of 72 cases(63.16%).Univariate analysis revealed statistically significant differences between the two groups in 23 factors(all P<0.05),including demographic data(age,admission to intensive care unit(ICU),death,length of hospital stay),laboratory findings(serum creatinine above normal,urea above normal,neutrophil percentage below normal,neutrophil percentage above normal,lymphocyte percentage below normal,serum sodium above normal),concomitant medications(nonsteroidal anti-inflammatory drugs(NSAIDs),antifungal agents,neurological drugs,adrenergic drugs,sodium bicarbonate tablets/injection,diphenhydramine/promethazine injection,NSAIDs^(+)diphenhydramine/promethazine,NSAIDs^(+)corticosteroids,diphenhydramine/promethazine+corticosteroids,NSAIDs+diphenhydramine/prome-thazine+corticosteroids),and comorbidities(diabetes mellitus,kidney disease,cardiac insufficiency)(all P<0.05).Multivariate analysis identified admission to the ICU(OR=2.128,95%CI:1.415-3.201),elevated serum creatinine at admission(OR=1.920,95%CI:1.235-2.985),and comorbid cardiac insufficiency(OR=3.394,95%CI:1.369-8.417)as risk factors,while prophylactic use of diphenhydramine/promethazine injection(OR=0.182,95%CI:0.083-0.399)or sodium bicarbonate tablets/injection(OR=0.512,95%CI:0.339-0.773)were protective factors.The prediction model equation is as follows.logit(P)=ln[P/(1-P)]=-0.479+0.755X_(1)+0.652X_(2)+1.222X_(3)-1.702X_(4)-0.67X_(5)(X_(1) admitted to the intensive care unit,X_(2) admitted to the hospital with higher serum creatinine than the normal value,X_(3) complicated with cardiac insufficiency,X_(4) combined with diphenhydramine/promethazine injection,X_(5) was combined with sodium bicarbonate tablets/injection,X was taken as“1”or“0”according to whether the conditions were met).The AUC of the model was 0.735(95%CI:0.691-0.780)in the training set and 0.699(95%CI:0.604-0.795)in the validation set.The Hosmer-Lemeshow test yielded a χ^(2) value of 4.048(P=0.774),indicating good model calibration.Conclusions Admission to the ICU,elevated serum creatinine at admission,and comorbid cardiac insufficiency as potential risk factors for AKI,while prophylactic use of diphenhydramine/promethazine or sodium bicarbonate showed a protective association.A predictive model with good discrimina-tion and calibration was developed,which may provide a basis for early identification of high-risk patients and timely adjustment of treatment strategies in clinical practice.
作者
谢昊
施奕迅
许治清
李敏权
杜小莉
陈罡
赵彬
XIE Hao;SHI Yixun;XU Zhiqing;LI Minquan;DU Xiaoli;CHEN Gang;ZHAO Bin(Department of Pharmacy,Peking Union Medical College Hospital,Chinese Academy of Medical Science&Peking Union Medical College,Beijing 100730,China;School of Traditional Chinese Medicine,Tianjin University of Traditional Chinese Medicine,Tianjin 301617,China;Department of Nephrology,Peking Union Medical College Hospital,Chinese Academy of Medical Science&Peking Union Medical College,Beijing 100730,China)
出处
《协和医学杂志》
北大核心
2026年第2期429-437,共9页
Medical Journal of Peking Union Medical College Hospital
基金
中央高水平医院临床科研专项(2022-PUMCH-B-058)
中国药学会医院药学专委会人才专项资助项目(CPA-Z05-ZC-2022-003)。
