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目的：分析严重创伤后发生急性肾损伤（AKI）并接受肾脏替代治疗（RRT）患者的病情特点，了解创伤导致AKI的危险因素以及RRT治疗时机对预后的影响。方法采用回顾性队列分析研究。研究对象为2011年8月至2014年12月浙江大学医学院附属第二医院急诊重症加强治疗病房（ICU）连续收治的严重创伤患者，纳入年龄≥18岁、损伤严重程度评分（ISS）＞16分、发生AKI并接受RRT治疗、住院时间＞24 h者。收集患者的一般资料、导致AKI的危险因素、预后指标，以及RRT相关资料。分别根据患者预后、AKI发生时间、RRT开始时间进行分组分析，采用logistic回归分析筛选患者预后的独立危险因素。结果符合纳入标准者共73例，死亡48例，病死率为65.8%。伤后AKI发生时间≤48 h者（早期AKI组）49例，＞48 h者（晚期AKI组）24例。按照传统标准开始RRT治疗者（常规RRT组）55例；在完全达到传统标准之前，主管医师根据病情发展趋势提前开始RRT治疗者（提前RRT组）18例。73例患者AKI危险因素中AKI前休克占90.4%， AKI前脓毒症占53.4%。与存活组比较，死亡组男性比例低（70.8%比100.0%，χ2＝7.238，P＝0.007），急性生理学与慢性健康状况评分系统Ⅱ（APACHEⅡ）评分高（分：23.7±5.1比14.4±3.7，t＝8.031，P＜0.001），格拉斯哥昏迷评分（GCS）低〔分：5.0（3.0，15.0）比15.0（8.0，15.0），U＝320.000，P＝0.001〕；AKI前休克发生率高（97.9%比76.0%，χ2＝6.755，P＝0.009），脓毒症发生率高（64.6%比32.0%，χ2＝7.014，P＝0.008），造影率使用率低（27.1%比56.0%，χ2＝5.898，P＝0.015）；伤后AKI发生时间晚〔d：2（1，5）比2（1，2），U＝762.000， P＝0.049〕，RRT开始时间晚〔d：6.0（3.0，12.0）比3.0（2.0，4.5），U＝868.500，P＝0.002〕；出院时肾功能恢复率低（10.4%比100.0%，χ2＝54.497，P＜0.001）。与晚期AKI组比较，早期AKI组病死率低（55.1%比87.5%，χ2＝7.509，P＝0.006），AKI前脓毒症发生率低（38.8%比83.3%，χ2＝12.854，P＜0.001）。提前RRT组患者出院时肾功能恢复率和病死率显示出优于常规RRT组的倾向，差异无统计学意义（55.6%比36.4%，χ2＝2.064， P＝0.151；50.0%比70.9%，χ2＝2.633，P＝0.105）。多因素logistic回归分析显示，GCS〔优势比（OR）＝0.852，95%可信区间（95%CI）＝0.747～0.972，P＝0.017〕、 AKI前休克（OR＝85.350，95%CI＝5.682～1282.073， P＝0.001）、 AKI前脓毒症（OR＝11.499，95%CI＝2.127～62.161，P＝0.005）为患者预后的独立危险因素。结论休克和脓毒症是严重创伤后需要RRT治疗患者发生AKI的主要危险因素；休克、脓毒症和颅脑损伤是此类患者死亡的独立危险因素；早于传统指征开始RRT治疗可能并不能改善预后。“,”ObjectiveTo analyze the characteristics of severe trauma patients with acute kidney injury (AKI) receiving renal replacement therapy (RRT), in order to look for the risk factors of AKI and the opportune time for the initiation of RRT on prognosis.Methods A retrospective cohort study involving consecutive patients with severe trauma in emergency intensive care unit (ICU) in the Second Affiliated Hospital of Zhejiang University School of Medicine, from August 2011 to December 2014, was conducted. Inclusion criteria included age≥18 years, injury severity score (ISS)> 16, AKI receiving RRT, and the duration of hospital stay> 24 hours. The general data, the risk factors of AKI, the prognostic indicators, and the information of RRT were recorded. All patients were divided into two groups according to the prognosis, the time of onset of AKI and the initiation time of RRT. The independent risk factors for prognosis were screened by binary logistic regression analysis.Results Seventy-three patients were eligible for enrollment, including 48 deaths (65.8%); 49 patients suffered from AKI≤48 hours after trauma (early stage group), and in 24 patients it was longer than 48 hours (late stage group). In 55 patients RRT was routinely started (routine RRT group), 18 patients underwent RRT ahead of routine criteria decided by the judgment of the attending doctor (earlier RRT group). The main risk factors of RRT in traumatic patients with AKI were shock and sepsis, each accounted for 90.4% and 53.4%. Compared with survival group, in death group, the proportion of male patients was lower (70.8% vs. 100.0%,χ2 = 7.238,P = 0.007), acute physiology and chronic health evaluationⅡ (APACHEⅡ) scores were higher (23.7±5.1 vs. 14.4±3.7,t = 8.031,P< 0.001), Glasgow coma score (GCS) was lower [5.0 (3.0, 15.0) vs. 15.0 (8.0, 15.0),U = 320.000,P = 0.001], incidence of shock and sepsis was higher (97.9% vs. 76.0%,χ2 =6.755,P = 0.009; 64.6% vs. 32.0%,χ2 = 7.014,P = 0.008), the rate of use of contrast medium was lower (27.1% vs. 56.0%,χ2 = 5.898,P = 0.015), the time for the diagnosis of AKI post trauma was delayed [days: 2 (1, 5) vs. 2 (1, 2), U = 762.000,P = 0.049], the time for the initiation of RRT post trauma was later [days: 6.0 (3.0, 12.0) vs. 3.0 (2.0, 4.5), U = 868.500,P = 0.002], the recovery rate of renal function at discharge was lower (10.4% vs. 100.0%,χ2 = 54.497, P< 0.001). Compared with late stage group, in early stage group, the mortality was lower (55.1% vs. 87.5%,χ2 =7.509,P = 0.006), and the incidence of sepsis before AKI was also lower (38.8% vs. 83.3%,χ2 = 12.854,P< 0.001). Compared with routine RRT group, the recovery of renal function at discharge was better with a lower mortality rate in the earlier RRT group, but the difference was considered to be insignificant (55.6% vs. 36.4%,χ2 = 2.064,P = 0.151;50.0% vs. 70.9%,χ2 = 2.633,P = 0.105). Logistic regression analysis showed GCS [odds ratio (OR) = 0.852, 95%confidence interval (95%CI) = 0.747-0.972,P = 0.017], shock before AKI (OR = 85.350, 95%CI = 5.682-1 282.073, P = 0.001), and sepsis before AKI (OR = 11.499, 95%CI = 2.127 - 62.161,P = 0.005) were independent risk factors for the judgment of prognosis.Conclusions Shock and sepsis are the major risk factors of RRT in trauma patients with AKI. Shock, sepsis and traumatic brain injury are the independent risk factors of death. Perhaps early initiation of routine RRT cannot improve the outcome of the patients with posttraumatic renal insuficiency.