대한내과학회지 : 제 84 권제 6 호 2013 http://dx.doi.org/10.3904/kjm.2013.84.6.818 대퇴골골절환자에서발생한급성신손상의위험인자와임상경과 가톨릭대학교의과대학 1 내과학교실, 2 정형외과학교실 윤유선 1 유지한 1 김지희 1 권기욱 1 이홍석 1 이영복 1 박원종 2 김영옥 1 Risk Factors and the Clinical Course of Acute Kidney Injury in Patients with a Femoral Fracture Yu-Seon Yun 1, Jihan Yu 1, Ji Hee Kim 1, Ki Wook Kwon 1, Hong Seok Lee 1, Yeong Bok Lee 1, Won Jong Bahk 2, and Young Ok Kim 1 Departments of 1 Internal Medicine and 2 Orthopaedic Surgery, The Catholic University of Korea College of Medicine, Seoul, Korea Background/Aims: Femoral fracture occurs most often in elderly patients and is highly associated with medical problems such as acute kidney injury (AKI); however no reports of AKI in femoral fracture patients have been published. This study was performed to identify risk factors and the clinical course of AKI in patients with femoral fracture. Methods: We retrospectively evaluated the medical records of 110 patients with femoral fracture between November 2006 and December 2011 at Uijeongbu St. Mary s Hospital. We investigated the incidence and clinical course of AKI in femoral fracture patients and compared the clinical findings between AKI and normal kidney function (NKF) groups. Results: Of the 110 femoral fracture patients, AKI was observed in 19 (17.3%). The peak serum creatinine level in patients with AKI was 2.59 ± 1.57 mg/dl. Two of 19 patients with AKI died and two progressed to chronic kidney disease. When compared to the NKF group, the AKI group had a higher incidence of elevated lactate dehydrogenase (LDH) (63.2% vs. 34.1%, p = 0.020), erythrocyte sedimentation rate (ESR) (31.6% vs. 6.6%, p = 0.008), and C-reactive protein (57.9% vs. 46.2%, p = 0.042). The AKI group also had a longer hospitalization duration, and more patients were prescribed an angiotensin-converting-enzyme (ACE) inhibitor than in the NKF group. Multivariate analysis demonstrated elevated LDH, ESR and ACE inhibitor prescriptions as independent risk factors for AKI in patients with a femoral fracture. Conclusions: The incidence of AKI in patients with a femoral fracture was 17.3%, and AKI was associated with a longer clinical course. We recommend monitoring of laboratory findings and medications and early management to reduce the morbidity of patients with AKI. (Korean J Med 2013;84:818-826) Keywords: Acute kidney injury; Femoral fractures; Risk factors Received: 2012. 9. 26 Revised: 2012. 11. 2 Accepted: 2012. 12. 3 Correspondence to Jihan Yu, M.D. Department of Internal Medicine, Uijeongbu St. Mary s Hospital, The Catholic University of Korea College of Medicine, 271 Cheonbo-ro, Uijeongbu 480-717, Korea Tel: +82-31-820-3504, Fax: +82-31-847-2719, E-mail: styjh@catholic.ac.kr Copyright c 2013 The Korean Association of Internal Medicine This is an Open Access article distributed under the terms of the Creative Commons Attribution - 818 - Non-Commercial License (http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted noncommercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
- Yu-Seon Yun, et al. Acute kidney injury in femur fracture - 서론노화에의하여여러장기기능이저하되며신장기능역시연령에따라감소한다. 또한연령이증가함에따라신기능감소를유발하는자극 ( 탈수, 약제 [NSAIDs], 조영제등 ) 에의하여급성신손상이발생할가능성이증가한다 [1]. 급성신손상이있을경우환자의이환율과사망률이증가한다는것은잘알려져있으며 [2,3], 수술후회복이지연되거나합병증이발생하는등의불량한임상경과와예후를동반하므로 [4,5] 고령환자에서수술시급성신손상발생여부를주의하여감시하여야한다. 대퇴골골절은주로외상, 특히낙상에의하여발생하며연령에따라골밀도가감소하고낙상의빈도가증가한다. 따라서고령환자에서대퇴골골절의발생이증가하며중요한입원의원인이된다 [6]. 또한연령자체뿐아니라고령환자에서흔히동반되는내과적질환들은이들환자군에서수술후합병증발생및재원기간의증가등의결과를초래할수있다 [7,8]. 이와같이대퇴골골절과급성신손상모두고령에서발생할가능성이높으며동반되었을경우불량한예후가예상된다. 외국의보고에의하면대퇴골골절환자에서급성신손상이발생하는경우사망률과재원기간이유의하게증가하며 [9], 혈중요소수치증가는사망률증가와관련됨을확인하였다 [10]. 또다른연구에서는만성신장병환자에서대퇴골골절위험도및사망률이증가함을보고하였다 [11,12]. 그러나대퇴골골절환자에서급성신손상발생의독립적인위험인자및임상경과를탐색한연구는없으며국내의연구자료도거의없다. 이에저자들은고령에서호발하는대퇴골골절과급성신손상의관계를확인하기위해, 후향적연구를통하여대퇴골골절환자에서급성신손상의발생빈도를조사하였다. 또한급성신손상발생여부에따라두군간의검사실소견과임상경과를비교하였으며급성신손상발생에영향을주는인자를확인하였다. 대상및방법대상 2006년 1월부터 2011년 12월까지 6년동안대퇴골골절로 가톨릭대학교의정부성모병원정형외과에입원한환자를대상으로하였다. 대퇴골골절은방사선학적으로 ( 단순 X-선, 혹은컴퓨터단층촬영 ) 증명된대퇴골두, 전자간, 대퇴경부혹은대퇴골기둥의골절이있는경우를대상으로하였다. 이중장기투석중에있어급성신손상여부를판단할수없는환자와교통사고등의다발성외상을동반한환자는대상에서제외하였다. 연구기간동안대퇴골골절로내원한환자는 113명이었으며이중연구기준에적합한환자는 110명이었다. 방법이연구는병원윤리위원회의승인하에시행하였으며연구결과및자료는위원회규정에의해수집및처리되었다. 대상환자의의무기록을통하여임상인자들과검사실항목을조사하였다. 일반적인인자로연령, 성별, 당뇨, 고혈압, 만성신장병, 심질환, 뇌졸중, 암등의과거력을조사하였으며, 방사선학적으로손상의종류및정도를분류하였다. 급성신손상은 KDIGO 진단기준에따라 [13] 혈청크레아티닌을기저치와비교하여 0.3 mg/dl 이상증가하거나 1.5배이상증가한경우로정의하였으며기저치를알수없는경우 ADQI 권장사항에따라 [14] 사구체여과율을 75 ml/min으로가정하여 MDRD 공식을통하여계산하였다. 급성신손상의임상경과로서발생시기, 초기및입원중혈청크레아티닌최대치와정상으로회복된시기등을조사하였다. 내원시검사실소견으로일반혈액검사, 혈액화학검사, 동맥혈검사를조사하였다. 이러한소견을바탕으로고령 ( 연령 65세이상 ), 백혈구증가증 (WBC > 10,000/mm 3 ), 빈혈 (Hb < 13 g/dl [ 남자 ], < 12 g/dl [ 여자 ]), 혈소판감소증 (platelet < 100 10 9 /L), 저나트륨혈증 (Na < 135 meq/l), 고칼륨혈증 (K > 5.5 meq/l), 간기능이상 (AST or ALT > 40 IU/L), CPK 증가 (CPK > 500 IU/L), LDH 증가 (LDH > 500 IU/L), ESR 증가 (ESR > 40 mm/h), CRP 증가 (CRP > 1.0 mg/l) 등을파악하여급성신손상이발생한환자군과정상신기능군을비교하였다. 또한두군간의수술시간, 수술중출혈량및적혈구수혈량을조사하였으며, 수술후합병증과재원기간, 입원중투약력을조사하였다. 통계분석결과는평균 ± 표준편차또는백분율 (%) 로표시하였다. 급성신손상군과정상신기능군사이의발생빈도비교는 - 819 -
- 대한내과학회지 : 제 84 권제 6 호통권제 634 호 2013 - Chi square test 혹은 Fisher s exact test를이용하였고, 평균비교는 independent t-test 혹은 Mann-Whitney test를시행하였다. 위의분석에서의미있는변수에대하여로지스틱회귀분석으로단변량분석을시행하였고분석결과의미있는인자에대해서다변량분석을시행하여급성신손상발생을예측할수있는인자를찾았다. 모든통계의유의수준은 95% 신뢰구간에서 p 값이 0.05 미만인경우로하였다. 결과대상환자의임상적특성전체대상자 110명의평균연령은 69.7 ± 16.6세 ( 범위 : 17-93세 ) 로남자 47명, 여자 63명이었다. 기저질환으로당뇨 34.5%, 고혈압 57.3%, 허혈성심질환 13.6%, 심부전 9%, 뇌졸중 19.1%, 암 5.5% 로조사되었다. 수상부위는대퇴경부가 88.2% 였으며그중에서도 Garden grade IV의발생이가장많았다. 대퇴골골절의원인은모두낙상이었으며피로골절, 병적골절등은없었다. 입원시시행한검사실소견및방사선소견은표 1과같다. 급성신손상발생빈도및임상경과전체대상환자 110명중급성신손상은 19명에서발생하여발생빈도는 17.3% 였다. 급성신손상환자 19명의입원시평균혈청크레아티닌치는 1.89 ± 1.5 mg/dl (0.79-7.21 mg/dl) 로급성신손상은입원후평균 8.2 ± 10.6 (1-41) 일에발생하였으며, 최대치는 2.59 ± 1.57 mg/dl (1.25-7.21 mg/dl) 이었다. 내원당시급성신손상이동반된경우는 7명이었으며수술전, 후각각 5명, 7명의환자에서급성신손상이발생하였다. 수술전그리고수술후급성신손상이발생한환자들의최대혈청크레아티닌수치는유의한차이가없었다 ( 내원시 & 수술전 vs. 수술후 : 2.15 ± 0.45 vs. 2.84 ± 0.50 mg/dl, p = 0.186). 심한신부전으로투석치료가필요하였던환자는 1명이었으며지속적신대체요법 (continuous renal replacement therapy) 을 5일간시행하였으나폐렴으로사망하였다. 급성신손상환자 19명중 2명이사망하였으며 (10.5%) 모두폐렴에의한패혈증으로사망하였다. 사망자 2명을포함한 6명의환자는퇴원시까지신기능이정상으로회복되지않았다. 이들중 3명은내원당시급성신손상이동반되어있었으며, 내원중급성신손상이발생한경우는수술전 2명, 수술후 1 명이었다. 생존자 4명중 2명은신기능이회복되지않은상태로외래추적관찰중에있고, 2명은퇴원이후추적이불가능하였다. 신기능이회복된 13명은기저신장가능까지회복되는데에평균 19.7 ± 17.04 (1-67) 일이소요되었다 (Fig. 1). 급성신손상군과정상신기능군사이의임상소견및검사실소견비교전체 110명의환자를급성신손상군 (n = 19) 과정상신기능군 (n = 91) 으로나누어임상소견과검사실소견을비교하였다. 급성신손상군은정상신기능군에비해모두 65세이상의고령의환자였으며 (100% vs. 72.5%, p = 0.004) 여성과당뇨환자의비율이높았다 ( 각각 78.9% vs. 52.7%, p = 0.036, 57.9% vs. 29.7%, p = 0.019). 또한기존에만성신장병으로진단되어추적관리중에있는경우급성신장병의빈도가높았다 (31.6% vs. 6.6%, p = 0.006). 그러나수상종류와정도는두군간에차이가없었다. 검사실소견에서 LDH (63.2% vs. 34.1%, p = 0.020), ESR (31.6% vs. 6.6%, p = 0.008) 및 CRP (57.9% vs. 46.2%, p = 0.042) 가증가된비율이급성신손상군에서높았다 (Table 2). 급성신손상군과정상신기능군간의이환율, 재원기간및투약력비교급성신손상군에서적혈구수혈량이더많았으나수술시간, 수술중출혈량, 수술중저혈압 ( 수축기혈압 < 90 mmhg) 발생여부는두군간차이가없었다. 급성신손상군은정상신기능군에비하여요로감염의빈도가높았다 (21.1% vs. 2.2%, p = 0.001). 전체환자중 5명 (4.5%) 이사망하였으며, 사망원인은폐렴에의한패혈증 3명, 심근경색 2명이었으나급성신손상군과정상신기능군간사망률의차이는없었다 (p = 0.205). 수상발생, 응급실내원, 수술, 퇴원시기를각각구분하여경과기간을비교하였으며급성신손상군에서수상발생혹은응급실내원부터수술까지걸리는기간과수술후퇴원까지의기간이유의하게길었다. 그러나총재원기간은양군간유의한차이는없었다. 재원중투약된약제는급성신손상군에서안지오텐신전환억제제 (ACEi) 가투여된경우가많았으나 (26.3% vs. 3.3%, p < 0.000) aminoglycoside, 이뇨제, 조영제와같이신독성을유발하는약제의투약력은두군간차이가없었다. 그러나 - 820 -
- 윤유선외 7 인. 대퇴골골절과급성신손상 - Table 1. Clinical, laboratory, and radiologic findings on admission Total (n = 110) AKI (n = 19) NKF (n = 91) p value Basic demographics & past history Age, yr 69.7 ± 1.6 77.7 ± 1.8 68.0 ± 1.8 0.027 Female sex 63 (57.3%) 15 (78.9%) 48 (52.7%) 0.036 Diabetes 38 (34.5%) 11 (57.9%) 27 (29.7%) 0.019 Hypertension 63 (57.3%) 14 (73.7%) 49 (53.8%) 0.112 CKD 12 (10.9%) 6 (31.6%) 6 (6.6%) 0.006 IHD 15 (13.6%) 5 (26.3%) 10 (11.0%) 0.077 Stroke 21 (19.1%) 6 (31.6%) 15 (16.5%) 0.128 Cancer 6 (5.5%) 2 (10.5%) 4 (4.4%) 0.276 Complete blood count WBC, mm 3 10,365 ± 3988 10,725 ± 1024 10,290 ± 409 0.314 Hb, g/dl 12.0 ± 1.9 11.3 ± 2.3 12.1 ± 1.8 0.094 Hct, % 35.6 ± 5.4 33.8 ± 6.9 36.0 ± 5.0 0.098 Platelet, 10 9 /L 227 ± 84 242 ± 22 224 ± 8.5 0.244 Blood chemistry BUN, mg/dl 21.4 ± 15.5 35.0 ± 6.3 18.5 ± 1.0 0.000 Cr, mg/dl 1.19 ± 0.87 1.89 ± 1.5 1.04 ± 0.06 0.000 Sodium, meq/l 139 ± 4.3 137 ± 1.0 139 ± 0.4 0.050 Potassium, meq/l 4.1 ± 0.6 4.5 ± 0.2 4.0 ± 0.1 0.001 Calcium, mg/dl 8.6 ± 0.8 8.4 ± 0.2 8.6 ± 0.1 0.318 Phosphorous, mg/dl 3.3 ± 0.7 3.6 ± 0.2 3.3 ± 0.1 0.078 AST, IU/L 32 ± 24 37 ± 6.5 31 ± 2.5 0.138 ALT, IU/L 23 ± 16 26 ± 3.9 22 ± 1.7 0.174 CPK, IU/L 346.7 ± 521.0 543.7 ± 239.5 297.4 ± 103.0 0.171 LDH, IU/L 522.1 ± 169.3 723.3 ± 77.2 529.9 ± 32.9 0.032 ESR, mm/hr 24.5 ± 18.3 46.7 ± 7.2 21.2 ± 2.5 0.007 CRP, mg/l 3.7 ± 4.6 5.8 ± 1.0 3.2 ± 0.6 0.014 ph 7.44 ± 0.06 7.43 ± 0.02 7.45 ± 0.01 0.096 Radiology Femoral neck 97 (88.2%) 19 (100%) 78 (85.7%) 0.859 Garden I 6 (5.5%) 1 (5.3%) 5 (5.2%) Garden II 1 (0.9%) 0 (0%) 1 (1.1%) Garden III 9 (8.2%) 1 (5.3%) 8 (8.8%) Garden IV 81 (73.6%) 17 (89.5%) 64 (70.3%) Femoral head 4 (3.6%) 0 (0%) 4 (4.4%) Intertrochanter 7 (6.4%) 0 (0%) 7 (7.7%) Femoral shaft 2 (1.8%) 0 (0%) 2 (2.1%) AKI, acute kidney injury; NKF, normal kidney function; IHD, ischemic heart disease; WBC, white blood cells; Hb, hemoglobin; Hct, hematocrit; BUN, blood urea nitrogen; Cr, creatinine; AST, aspartate aminotransferase; ALT, alanine aminotransferase; CPK, creatinine phosphate kinase; LDH, lactate dehydrogenase; ESR, erythrocyte sedimentation rate; CRP, C-reactive protein. - 821 -
- The Korean Journal of Medicine: Vol. 84, No. 6, 2013 - ACEi와안지오텐신수용체저해제 (ARB) 복용을함께고려한경우급성신손상군에서비교적그빈도가높았으나 (p = 0.056) 통계적유의성은없었다 (Table 3). 대상환자중급성신손상발생의독립위험인자분석급성신손상군과정상신기능군간에차이를보인소견들에대해단변량분석 (Table 4) 에서의미있는인자들을대상으로다변량로지스틱분석을시행하였다. 다변량분석에서 LDH 증가 (OR 27.644, 95% C.I. 1.156-660.807), ESR 증가 (OR Figure 1. Serum creatinine level during hospital days. 9.574, 95% C.I. 1.176-77.957), ACEi 투여 (OR 198.646, 95% C.I. 2.986-13216.654) 가급성신손상발생을증가시키는독립적인위험인자로나타났다 (Table 4). 고찰급성신손상과동반된불량한임상경과는여러연구에서보고되고있으며특히외상 [12], 응급실내원환자 [15], 수술환자 [16] 의사망률및이환율을증가시키는것으로알려져있다. 대퇴골골절과급성신손상은모두고령에서호발하고대퇴골골절과급성신손상이동반될경우불량한임상경과를예상할수있으나이에대한연구는이루어져있지않았다. 이에본연구에서는대퇴골골절환자에서급성신손상의발생빈도, 임상경과, 그리고급성신손상발생의위험인자를살핌으로써대퇴골골절환자에서발생하는급성신손상의임상적특징을밝히고자하였다. 본연구에서대퇴골골절환자에서급성신손상의발생빈도는 13.4% 였으며급성신손상이발생한군에서고령, 여자, 당뇨환자의비율이높았고, ESR, CRP, LDH 등급성염증지표들의유의한증가가관찰되었다. 또한 ACEi를복용하고있는경우가많았으나, aminoglycoside, 이뇨제, 조영제등과같은신독성이있는약제는급성신손상발생과유의한상관관계가없는것으로나타났다. 또한급성신손상군에서입원에서수술까지소요되는기간과수술후재원기간이더길었다. 이러한요인들중 ESR, LDH 증가및 ACEi 복용이대퇴골골절환자에서급성신손상발생의독립적인위험인자로나타났다. Table 2. Categorical comparison of laboratory findings between the AKI and NKF groups Total (n = 110) AKI (n = 19) NKF (n = 91) p value Old age (> 65 yr) 85 (77.3%) 19 (100%) 66 (72.5%) 0.004 Leukocytosis 54 (49.1%) 10 (52.6%) 44 (48.4%) 0.465 Anemia 63 (57.3%) 13 (68.4%) 50 (54.9%) 0.206 Hyponatremia 20 (18.2%) 5 (26.3%) 15 (16.5%) 0.240 Hyperkalemia 2 (1.8%) 2 (10.5%) 0 (0%) 0.029 Abnormal LFT 23 (20.9%) 6 (31.6%) 17 (18.7%) 0.176 Increased CPK 6 (5.5%) 3 (15.8%) 3 (3.3%) 0.075 Increased LDH 43 (39.1%) 12 (63.2%) 31 (34.1%) 0.020 Increased ESR 12 (10.9%) 6 (31.6%) 6 (6.6%) 0.008 Increased CRP 53 (48.2%) 11 (57.9%) 42 (46.2%) 0.042 LFT, liver function test; AKI, acute kidney injury; NKF, normal kidney function. - 822 -
- Yu-Seon Yun, et al. Acute kidney injury in femur fracture - Table 3. Comparisons of complications and hospital courses between the AKI and NKF groups AKI (n = 19) NKF (n = 91) p value OP time, hr 90.5 ± 18.1 (70-120) 97.5 ± 39.3 (40-244) 0.499 Total blood loss, ml 668.2 ± 494.9 (50-1600) 499.5 ± 340.1 (5-2000) 0.137 PRC transfusion, U 1.67 ± 1.07 (0-3) 0.74 ± 0.91 (0-3) 0.003 IntraOP hypotension 46.2% (n = 6) 27.4% (n = 23) 0.429 Complications UTI 21.1% (n = 4) 2.2% (n = 2) 0.001 Resp. infection 15.8% (n = 3) 9.9% (n = 9) 0.389 GI bleeding 10.5% (n = 2) 2.2% (n = 2) 0.124 Re-OP 0% (n = 0) 4.4% (n = 4) 1.000 Death 10.5% (n = 2) 3.3% (n = 3) 0.205 Hospital days Injury-ER 18.0 ± 62.6 (0-273) 7.75 ± 34.3 (0-306) 0.429 Injury-OP 34.6 ± 73.7 (7-277) 12.6 ± 34.8 (0-308) 0.002 ER-OP 8.9 ± 4.8 (1-21) 4.8 ± 4.1 (0-14) 0.001 OP-discharge 25.9 ± 19.4 (14-70) 18.4 ± 13.6 (4-83) 0.046 ER-discharge 28.0 ± 21.4 (5-91) 22.66 ± 13.9 (2-90) 0.142 Medication Aminoglycoside 10.5% (n = 2) 18.7% (n = 17) 0.383 ACE inhibitor 26.3% (n = 5) 3.3% (n = 3) 0.000 ARB 26.3% (n = 5) 22.0% (n = 20) 0.700 ACE inhibitor or ARB 47.4% (n = 9) 25.3% (n = 23) 0.056 Diuretics 68.4% (n = 13) 57.1% (n = 52) 0.390 Contrasts 47.4% (n = 9) 36.3% (n = 33) 0.384 OP, operation; PRC, packed red cell; UTI, urinary tract infection; GI, gastrointestinal; ER, emergency room; ACE, angiotensin converting enzyme; ARB, angiotensin receptor blocker; AKI, acute kidney injury; NFK, nomal kidney function. 대퇴골골절환자에서급성신손상이발생하는기전은다른외상에서급성신손상이발생하는기전과유사할것으로생각된다 [12,17]. 즉, 혈역학적불안정에의한신혈류감소, 크레아티닌, 마이오글로불린등의근육효소파괴로인한내인성신독성인자발생, 치료과정에서투여되는약제에의해신손상이발생하는것으로예상할수있다. 본연구는낙상에의한대퇴골골절환자를대상으로하였으며다발성외상환자는제외되었으므로내원시저혈압을보이는경우는없었다. 수술중출혈량과저혈압발생빈도는급성신손상군과정상신기능군간에통계적으로의미있는차이는없었으나급성신손상군에서다소높은경향을보였다 ( 각각 668.2 ± 494.9 vs. 499.5 ± 340.1 [p = 0.137], 46.2% vs. 27.4% [p = 0.429]). 또한 ACEi 혹은 ARB를복용한경우역시통계적인유의성은없었으나급성신손상군에서높게나타났다 (47.4% vs. 25.3%, p = 0.056). 혈압저하혹은체내순환혈류량이부족할때의 ACEi/ARB 복용은수출세동맥의수축을막아신장의방어기전을억제함으로서사구체내혈류량감소를가속화하여신손상이진행할수있다 [18]. 이는장기적인 ACEi 복용환자에서심장 [19], 대동맥수술시 [20] 급성신손상의증가가보고된바와같다. 본연구는의무기록은이용한후향적사례- 대조군연구이며대상자의수가 100여명이므로 ACEi/ARB 의복용이급성신손상을유발하였을것으로단정할수는없으나, 급성신손상군과정상신기능군간에 ACEi/ARB 복용정도의상당한차이가있으므로급성신손상의위험이높은환자에게서이들약제의투약을주의하여야겠으며더적극적인신기능의추적관찰및수액보충이바람직할것이다. 향후재원기간중혈압변화, 수상후, 수술전후적절한수액보충과급성신손상의임상경과에대한연 - 823 -
- 대한내과학회지 : 제 84 권제 6 호통권제 634 호 2013 - Table 4. Univariate and multivariate analysis of risk factors for AKI in patients with femoral fracture Regression coefficient p value Adjusted odds ratio 95% CI Univariate Age, > 65 yr 20.232 0.999 - - Sex (female) 1.212 0.044 3.359 1.035-10.902 Diabetes 1.181 0.023 3.259 1.180-9.000 Hyperkalemia 19.063 0.996.. Increased LDH 1.292 0.026 3.639 1.167-11.350 Increased ESR 1.969 0.006 7.167 1.736-29.583 Increased CRP 1.493 0.063 4.452 0.924-21.466 ACE inhibitor 2.338 0.003 10.357 2.223-48.245 Multivariate Sex (female) 2.004 0.167 7.417 0.433-127.147 Diabetes 1.597 0.267 4.940 0.294-82.889 Increased LDH 3.319 0.040 27.644 1.156-660.807 Increased ESR 2.259 0.035 9.574 1.176-77.957 ACE inhibitor 5.292 0.013 198.646 2.986-3216.654 구가필요하리라생각한다. 본연구결과급성신손상군에서 ESR, CRP, LDH 등급성염증인자의의미있는상승이나타났다. 수술후이인자들을연속적으로측정하였을때지속적으로상승되어있는경우심한조직손상이나감염등을시사하므로불량한예후와관련있음을추측할수있다 [21,22]. 본연구에서환자들의대부분은수상후일정시간경과후 (9.58 ± 40.6일 ) 병원에내원하였으므로내원당시급성염증인자들이충분히상승할시간이경과되었을것으로보인다. 따라서입원당시측정한염증인자들은환자의염증정도를비교적정확히반영할수있을것으로판단할수있다. 즉, 내원당시이미전신염증상태가진행되어있거나조직손상의범위가큰경우급성신손상이잘발생할것으로예상할수있으며이러한환자의경우혈청크레아티닌수치가정상이더라도향후신기능저하의가능성을염두에두어야하겠다. 급성신손상군에서급성염증인자의의미있는상승이나타난반면빈혈, 전해질이상등비교적만성적인인자들은의미있는차이를보이지않았는데, 이는본연구대상자들의골절원인이기존질환에의한것이아니라모두낙상이었기때문으로생각한다. 반면피로골절이나병적골절등의경우라면과거력및빈혈, 간기능이상등환자의만성적인상태를반영하는인자에도차이가있을것으로추측하며수술후합병증의빈도도유의한차이점이있을것으로생각 한다. 골절의대부분이대퇴경부골절이었으나골절의정도를나타내는 Garden grade에따른급성신손상발생의유의한차이는나타나지않았다. Garden grade는골절의정도, 골절편의편위정도등골절을기계학적으로설명하는지표로서수술방법의차이및수술후예후 ( 불유합, 전위등 ) 를예상하기위한지표이므로환자의임상적경과와급성신손상발생의예상에적용하는것에는적합하지않은것으로생각된다. 따라서본연구대상에서와같이혈역학적으로안정한환자들중에서는수상의종류와정도에따라서는급성신손상의정도의차이는없는것으로판단할수있다. 외상환자에서급성신손상의발생빈도는연구에따라차이가있으나 8.5-31% 로보고되고있으며 [12,23,24]. 이는본연구결과 (13.4%) 와비교하여큰차이가없는것으로보인다. 그러나사망률은기존문헌에서는 40-70% 로보고된반면 [12,23-25] 본연구에서는 10.5% 로비교적적게관찰되었으며급성신손상군의사망률이정상신기능군보다높았으나통계적으로유의한차이는없었다 (10.5% vs. 3.3% [p = 0.205]). 이는본연구에서는급성신손상의기준이 RIFLE 기준에서 R (Risk) 단계까지모두포함된것으로서비교적경증의급성신손상도포함되었으며, 다발성중증외상은제외되었고, 양군에서모두사망자의수가적었기때문으로생각한다. 그러나급성신손상군이정상신기능군과비교하여수상후 - 824 -
- 윤유선외 7 인. 대퇴골골절과급성신손상 - 수술까지의소요기간과수술후퇴원까지의재원기간이더길었으며, 적혈구수혈량도더많은것으로보아대퇴골골절환자에서급성신손상의동반은불량한임상경과와관련있음을시사한다. 본연구의제한점은다음과같다. 1) 후향적으로의무기록을조사하는연구이므로급성신손상을정의할때에혈중크레아티닌수치만으로판단하였으며소변량감소에의한급성신손상기준은적용하지못하였다. 따라서실제로발생한급성신손상환자수보다적게관찰되었을가능성이있다. 2) 대퇴골골절환자에서급성신손상의발생빈도와위험인자를조사하였으나대퇴골골절자체가급성신손상에미치는영향은확인하지못하였다. 다른골절혹은외상환자에서발생하는급성신손상과대퇴골골절환자에서발생하는급성신손상에대한비교연구가필요할것으로사료된다. 3) 급성신손상의원인을신전성 (prerenal), 신성 (renal) 및신후성 (postrenal) 로구분하여확인하지못하였다. 급성신손상이발생한환자에서요검사를충분히하지못한경우가많아 FENa 등의지표를구할수없었기때문이다. 결론적으로본연구결과 ESR, LDH 상승및 ACEi 복용은대퇴골골절환자에서급성신손상발생을예측할수있는유의한인자였다. 급성신손상은주로입원초기에나타나며발생빈도는약 17.3% 이며정상신기능환자에비하여재원기간이길고불량한예후가예상된다. 연속적으로혈청크레아티닌수치를측정함으로써신장기능을확인하는것은간단하면서도환자의예후를예측할수있는유용한정보를제공한다. 또한아직신기능이저하되지않았다하더라도본연구에서와같이고령, 동반질환, 급성염증인자가증가되어있는경우급성신손상발생의위험성이높음을예상하고더욱면밀하게환자의상태를살피며이상이있을경우신장내과의사와의협진을통하여조기에치료하는것이환자의예후를향상시키는데에도움이될것이다. 자하였다. 방법 : 2006년 11월부터 2011년 12월까지 6년동안대퇴골골절로의정부성모병원정형외과에입원한 110명을대상으로, 환자들의병력, 검사실소견, 방사선소견, 수술기록등의의학적기록을후향적으로검토하여대퇴골골절환자에서의급성신손상의발생빈도와위험인자, 그리고임상경과를조사하였다. 결과 : 전체 110명의환자중급성신손상은 19명에서발생하였다 (17.3%). 재원중혈청크레아티닌최고치는 2.59 ± 1.57 mg/dl으로내원 8.2 ± 10.6일에발생하였다. 급성신손상군 19명중 2명이사망하였고 2명은만성신부전증으로진행되었으며, 13명에서신기능이정상으로회복되었다. 회복까지는약 19.7 ± 17.04일이소요되었다. 급성신손상군은정상신기능군에비하여고령, 여성, 당뇨환자가많았으며, 검사실소견에서 LDH (63.2% vs. 34.1%, p = 0.020), ESR (31.6% vs. 6.6%, p = 0.008), CRP (57.9% vs. 46.2%, p = 0.042) 가증가된비율이높았다. 또한급성신손상군에서수상발생부터수술까지걸리는시간과수술후재원기간이길었으며, 엔지오텐신전환효소억제제 (ACEi) 의복용빈도가높았다 (26.3% vs. 3.3%, p < 0.000). 이상위험인자들에대한다변량분석에서 LDH 증가 (p = 0.040, 95% C.I. 1.156-660.807), ESR 상승 (p = 0.035, 95% C.I. 1.176-77.957), ACEi 복용 (p = 0.013, 95% C.I. 2.986-13216.654) 이급성신손상발생을유의하게증가시키는위험인자로확인되었다. 결론 : 대퇴골골절환자에서급성신손상은 17.3% 에서발생하였고이들중 10% 는만성신질환으로진행되었다. 대퇴골골절환자에서급성신손상발생의독립적인위험인자는 LDH, ESR 증가, ACEi 복용으로나타났다. 따라서대퇴골골절환자에서급성신손상발생가능성을염두에두고검사실소견및복용약제를감시하여적극적인초기치료로급성신손상을조기에치료하는것이중요하다고생각한다. 요 약 중심단어 : 급성신손상 ; 대퇴골골절 ; 위험인자 목적 : 대퇴골골절은주로고령에서발생하며급성신손상등내과적합병증의빈도가높으나대퇴골골절환자에서의급성신손상의위험인자와임상경과에대한연구는부족하다. 이에대퇴골골절환자에서의임상양상, 검사실소견등을비교하여급성신손상의위험인자와임상경과를조사하고 REFERENCES 1. Maaravi Y, Bursztyn M, Hammerman-Rozenberg R, Stessman J. Glomerular filtration rate estimation and mortality in an elderly population. QJM 2007;100:441-449. 2. Kim BS. Acute kidney injury: definition, incidence, etiology, - 825 -
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