背景：

急性心力衰竭合并急性肾损伤是一种发病率较高、预后极差、死亡率极高的临床综合征，通常由于心脏功能和结构改变引起的肾脏灌注不足、静脉淤血或局部损伤所致，因此入院后常需紧急治疗和护理以提高患者的生存率。在这类患者中，容量超负荷是一种常见且严重的病理状态，不仅导致患者的心肾功能持续性恶化，显著增加了院内死亡风险。此外，容量超负荷还可能导致患者在出院后需要长期的心肾替代治疗，从而极大降低了患者的生活质量，并给患者及其家庭带来沉重的经济负担。由护士主导的住院早期且有效的容量管理对于改善患者的预后起到关键性作用。护士通过不同评估方法，严密监测患者的入院后的容量状态，可以早期识别患者发生容量超负荷的高危因素，及时反映患者的异常病情变化，并给予合理的医疗和护理措施处理，从而提高患者的生存率和生活质量。由于急性心力衰竭合并急性肾损伤的病理机制较为复杂，其临床护理实践差异性较大，且暂无对此类患者的规范性护理容量管理方案。与此同时，护士对此类疾病的了解较少，目前容量管理实践多基于传统心力衰竭或肾脏病的容量管理经验，但大部分患者在住院期间并未得到合适的护理观察和管理。鉴于此，亟需构建针对急性心力衰竭合并急性肾损伤患者特点的容量管理的护理方案，并规范临床护理实践，以确保患者能够获得更加个性化和全面化的临床护理和居家护理指导，从而改善患者的预后。

目的：

描述住院期间急性心力衰竭合并急性肾损伤患者容量超负荷的动态变化，明确此类患者发生容量超负荷的独立风险因素，并构建急性心力衰竭合并急性肾损伤患者住院期间容量管理的护理方案。

方法：

本研究分为2个部分。第一部分采用回顾性队列研究，连续纳入2022年5月1日～2023年12月31日就诊于北京市某三级甲等心血管医院ICU、HFCU和肾内科的222例急性心力衰竭合并急性肾损伤患者。本研究采用了一组相同的数据进行了两次研究，分别以估计血浆容量和累积容量超负荷百分比两个结局指标判定是否发生容量超负荷，并使用回顾性队列研究方法，收集了相关数据并分析了第一个结局指标，接着基于同一组数据，采用了类似的回顾性队列研究方法，将第二个结局指标作为研究重点进行分析。数据的收集和分析过程在两次研究中保持了一致，以确保结果的可比性和准确性。详细的研究设计和方法将在后续部分中进行介绍。第一个回顾性队列研究以估计血浆容量为结局判断是否发生容量超负荷分为容量超负荷组75例和非容量超负荷组147例；第二个回顾性队列研究以累积容量超负荷百分比为结局判断是否发生容量超负荷分为容量超负荷组50例和非容量超负荷组172例。收集患者的一般资料以及随急性肾损伤发生、发展过程中的体重、出入量、影像学、实验室等数据，描述急性心力衰竭合并急性肾损伤患者住院期间的容量动态变化，通过两个回顾性队列分别进行单因素分析、广义线性混合模型分析急性心力衰竭合并急性肾损伤患者发生容量超负荷的潜在风险因素。第二部分，基于第一部分分析得到的急性心力衰竭合并急性肾损伤患者发生容量超负荷的独立风险因素结果，通过文献回顾、小组讨论、专家会议法，构建急性心力衰竭合并急性肾损伤患者住院期间容量管理的护理方案。

结果：

1.第一部分结果：

住院期间急性心力衰竭合并急性肾损伤患者的平均估计血浆容量为4.68 dl/g，平均累积容量超负荷百分比为-1.29 %，其中估计血浆容量较高值出现在第1天、第4天和第5天，而累积容量超负荷百分比出现在第1天、第2天和第5天。在急性肾损伤发生的后48h（第5天）的容量超负荷程度最高，估计血浆容量为4.86（3.60, 6.85）dl/g，累积超负荷百分比为0.05（-12.10, 12.01）%；在急性肾损伤发生前24h和当日容量超负荷程度最低，其中估计血浆容量为4.43（3.48, 6.62）dl/g，累积超负荷百分比为-1.87（-14.58, 9.48）%； 容量状态的动态变化呈现先下降后上升的趋势。

根据估计血浆容量为结局的患者发生容量超负荷的独立风险因素有年龄（β = 0.019, P = 0.037）、性别（β = -0.548 , P = 0.031）、缺血性心脏病史（β = 0.426, P = 0.042）、急性心力衰竭分类（β = -0.133, P = 0.017）、使用CRRT治疗（β = 0.516, P = 0.014）、入院舒张压（β = -0.019, P = 0.030）、血清白蛋白（β = -0.039, P＜ 0.001）、血清钾（β = -0.124, P＜ 0.001）。

根据累积容量超负荷百分比为结局的患者发生容量超负荷的独立风险因素为随急性肾损伤发生的时间变化（β = -0.885, P < 0.001）。

2.第二部分结果：

（1）13名临床医学及护理专家判断系数为0.965，专家熟悉程度为 0.838，专家权威程度为0.902。

（2）急性心力衰竭合并急性肾损伤患者住院期间容量管理方案包含了入院评估、心肾功能的动态评估、疾病管理、容量动态评估、容量管理、营养支持护理、健康教育、出院随访8个主题的内容。

结论：

1.在急性心力衰竭合并急性肾损伤患者中，住院期间容量超负荷程度呈现波动性，尤其在AKI发生前48小时和AKI发生后48小时，患者的容量超负荷程度可能更高，这提示了容量管理对AKI的发生和发展可能有一定预测作用，而其变化呈现先下降再上升的趋势，可能与容量超负荷程度上升后利尿剂治疗有关。

2.老年人、男性患者、既往有缺血性心脏病史、入院时湿暖和湿冷类急性心力衰竭、入院舒张压、住院时使用CRRT治疗、血清白蛋白越低、血清钾浓度越低的患者可能住院期间会出现容量超负荷的情况，且胸腔积液程度更严重、住院时间更长，应重视重点人群的疾病和容量评估及管理，并对患者及家庭进行合适的健康宣教。

3.本研究通过回顾性研究、文献回顾和专家会议法构建的急性心力衰竭合并急性肾损伤的容量管理方案，具备较高的可信度、科学性，并且在临床应用中具有实际价值。

Background: Acute heart failure combined with acute kidney injury is a clinically complex syndrome with high incidence rate, poor prognosis, and elevated mortality. Typically, it arises from inadequate renal perfusion, venous congestion, or local injury induced by alterations in cardiac function and structure. Consequently, immediate treatment and nursing care are often required after admission to enhance patient survival. Among these patients, fluid overload emerges as a common and serious pathological condition, exacerbating the continuous deterioration of cardio-renal function and significantly improving in-hospital mortality risk . Moreover, it may necessitate prolonged cardiac and renal replacement therapy post-discharge, substantially compromising patient quality of life and imposing substantial economic burdens on both patients and their families. Early and effective fluid management led by nurses plays a pivotal role in improving patient prognosis. Through various assessment methods, nurses monitor patients' fluid status during admission time, enabling the early identification of high-risk factors for fluid overload and prompt response to abnormal clinical changes. By administering appropriate medical and nursing interventions, nurses play a crucial role in improving patient survival and enhancing quality of life. However, the clinical practice of fluid management for patients with acute heart failure combined with acute kidney injury remains heterogeneous, with no standardized nursing protocol available. At the same time, nurses have limited understanding of such conditions, and current fluid management practices are mostly based on traditional experiences in managing heart failure or kidney diseases. However, the majority of patients do not receive adequate nursing observation and management during hospitalization. In light of these problems, it is imperative to develop fluid management to the unique characteristics of patients with acute heart failure combined with acute kidney injury. In the other hand nursing best practices is essential to ensure patients receive individualized and comprehensive nursing care, so as to improving patient’s clinical outcomes.

Objective:

To describe the dynamic changes of fluid overload in patients with acute heart failure combined with acute kidney injury during hospitalization, elucidate the independent risk factors associated with fluid overload in such patients, and develop a nursing protocol for fluid management during hospitalization for acute heart failure complicated acute kidney injury patients.

Methods:

The study was divided into two parts. In the first part, a retrospective cohort study was conducted, involving 222 patients with acute heart failure combined with acute kidney injury who were consecutively admitted to the ICU, HFCU, and Nephrology Department of a tertiary grade-A cardiovascular hospital in Beijing, China, from May 1, 2022, to December 31, 2023. The same dataset was utilized for two separate analyses, with outcomes defined as estimated plasma fluid and percentage of cumulative fluid overload, respectively, to determine the occurrence of fluid overload. Using a retrospective cohort study approach, relevant data were collected and analyzed for the first outcome measure. Subsequently, based on the same dataset, a similar retrospective cohort study approach was employed, focusing on the second outcome measure for analysis. Data collection and analysis processes remained consistent across both studies to ensure comparability and accuracy of results. Detailed study design and methods will be presented in subsequent sections.For the first retrospective cohort study, patients were divided into fluid overload (n=75) and non-fluid overload (n=147) groups based on estimated plasma fluid as the outcome measure for determining fluid overload occurrence. For the second retrospective cohort study, patients were categorized into fluid overload (n=50) and non-fluid overload (n=172) groups based on the percentage of cumulative fluid overload as the outcome measure for determining fluid overload occurrence. General patient information and data related to the course of acute kidney injury development, including weight, fluid intake and output, imaging, and laboratory findings, were collected to describe the dynamic changes in fluid status during the hospitalization of patients with AHF combined with AKI. Univariate analysis and generalized linear mixed model analysis were conducted separately for each retrospective cohort to identify potential risk factors for fluid overload in patients with AHF combined with AKI.In the second part of the study, based on the independent risk factors for fluid overload occurrence in patients with AHF combined with AKI identified in the first part, a nursing protocol for fluid management during hospitalization of these patients was developed through literature review, group discussions, and expert meetings.

Result:

1.The results of part one are as follows:

The average estimated plasma volume of patients with acute heart failure combined with acute kidney injury during hospitalization was 4.68 dl/g, with an average cumulative volume overload percentage of -1.29%. Elevated estimated plasma volume values were observed on days 1, 4, and 5, while cumulative volume overload percentages peaked on days 1, 2, and 5. The highest degree of volume overload occurred 48 hours after the onset of acute kidney injury (day 5), with an estimated plasma volume of 4.86 (3.60, 6.85) dl/g and a cumulative overload percentage of 0.05 (-12.10, 12.01)%. The lowest degree of volume overload occurred in the 24 hours before and on the day of acute kidney injury onset, with estimated plasma volumes of 4.43 (3.48, 6.62) dl/g and cumulative overload percentages of -1.87 (-14.58, 9.48)%, respectively. The dynamic changes in volume status showed a trend of initial decline followed by subsequent increase.

(2) The results indicated that independent risk factors for the occurrence of fluid overload in patients with estimated plasma volume as the outcome were as follows: age (β = 0.019, P = 0.037), gender (β = -0.548, P = 0.031), history of ischemic heart disease (β = 0.426, P = 0.042), classification of acute heart failure (β = -0.133, P = 0.017), use of continuous renal replacement therapy (CRRT) (β = 0.516, P = 0.014), admission diastolic blood pressure (β = -0.019, P = 0.030), serum albumin (β = -0.039, P < 0.001), and serum potassium (β = -0.124, P< 0.001).

(3) According to the cumulative fluid overload percentage as the outcome, the independent risk

factor for developing volume overload in patients was the time elapsed with the progression of acute kidney injury (β = -0.885, P < 0.001). The dynamic changes in fluid status exhibited a trend

of initial decline followed by subsequent increase.

2.The results of part two are as follows:

(1) The judgment coefficient of 13 clinical medicine and nursing experts was 0.965, with experts' familiarity rated at 0.838 and their authority at 0.902.

(2) The inpatient volume management protocol for patients with acute heart failure combined with acute kidney injury includes seven main themes: admission assessment, dynamic assessment of cardiac and renal function, disease management, dynamic volume assessment, volume management, nutritional support nursing, health education, and discharge follow-up.