体外循环与非体外循环冠状动脉旁路移植术后肾损害的危险因素分析

Risk Factors Analysis of Kidney Injury after On-pump and Off-pump Coronary Artery Bypass Grafting

目的探讨非体外循环冠状动脉旁路移植术（off—pump CABG）或体外循环冠状动脉旁路移植术（on—pump CABG）患者术后肾损害的危险因素，旨在为术后提供较好的肾保护措施。方法对自1990年1月至2006年8月收治的849例单纯行冠状动脉旁路移植术（CABG）患者的临床资料进行回顾性分析。采用单因素和logistic多因素分析术后急性肾损害（AKI）的风险因素。结果off—pump CABG患者中发生AKI 61例（11．8％，61／518），on—pump CABG患者中发生AKI63例（19．0％，63／331）。行off—pump CABG患者的血清肌酐（Scr）峰值时间为术后12h，on—pump CABG患者为术后24h；off—pump CABG术后有AKI患者Scr快速恢复期为24～48h，on—pump CABG术后有AKI患者为48～72h。logistic回归多因素分析结果显示：大体重指数（OR=1．190，1．179）、急诊手术（OR=2．737，3．678）、合并糖尿病（OR=1．705，2．042）、外周血管疾病（DR=2．002，2．559）、射血分数≤30％（OR=2．267，4．606）和心功能Ⅲ～Ⅳ级（OR=1．861，1．957）为off—pump CABG和on—pump CABG患者术后发生AKI的独立风险因素；脉压差≥60mmHg、冠状动脉3支病变为off—pump CABG患者术后发生AKI的独立风险因素；而术中和术后使用主动脉内球囊反搏（IABP）对行on—pump CABG患者术后肾功能具有保护作用（OR=0．146），可减少AKI发生的可能。结论对AKI预防和治疗的关键期为麻醉至off-pump CABG术后48h和on—pump CABG术后72h。AKI是病情发展的重要阶段，肾功能检测阳性结果提示可能有肾损害存在，并通过有效的措施和治疗方法阻止肾功能进一步恶化，使肾功能逆转。

Objective To investigate the risk factors of acute kidney injury（AKI）after on-pump coronary artery bypass grafting（on-pump CABG） and off-pump coronary artery bypass grafting （off-pump CABG） in order to provide superior renal protective measure after operation. Methods The clinical data of 849 consecutive patients undergone coronary artery bypass grafting （CABG） in a single institution between January 1990 and August 2006 were retrospectively analyzed. A simplex module and a multivariate logistic regression model were constructed to identify risk factors for the development of AKI. Results AKI were occurred in 61 patients （11.8%, 61/518） undergone off-pump CABG and 63 patients （19.0% ,63/331） undergone on pump CABG. Peak of serum creatinine （Scr） after operation arrived at the 12th hour and 24th hour in patients undergone off-pump CABG and patients undergone on-pump CABG respectively. The rapidly recovering period of Scr in patients undergone off-pump CABG and on-pump CABG were from the 24th hour to the 48th hour and from the 48th hour to the 72th hour respectively. The results of the multivariate forward stepwise logistic regression analysis found that risk factors for the development of postoperative AKI following isolated CABG were associated with heavy body mass index（OR ： 1. 190, 1. 179）, emergent procedure （OR =2. 737,3. 678）, diabetes （OR= 1. 705,2. 042）, peripheral vascular disease （OR = 2. 002, 2. 559）, ejection fraction≤30%（OR=2. 267,4. 606）, and New York Heart Association（NYHA） class Ⅲ and Ⅳ （OR= 1. 861,1. 957） were risk factors for the development of postoperative AKI following off-pump and on-pump CABG; pulse pressure≥60mmHg and triple-vessel disease were risk factors for the development of postoperative AKI following off-pump CABG. But perioperative and postoperative intra aortic balloon pumping （IABP） could make protective effect on kidney for on-pump CABG （OR=0. 146）which could lessen development of AKI. Conclusions It is critical period for AKI that renal protection strategies should be performed from general anesthesia until postoperative 48 hours （off-pump CABG） and 72 hours （on-pump CABG）. AKI might be the most important stage in which a positive test should increase the physician＇s awareness of the presence of risk for renal injury and then preventive or therapeutic intervention could be performed when the situation still is reversible.