急性肾损伤是影响心脏手术后患者长期生存的危险因素

Acute kidney injury is a risk factor for the long-term prognosis of cardiac surgery

目的了解心脏术后急性肾损害（AKI）患者的长期预后情况及探讨有关危险因素。方法选择2004年1月1日至2007年6月30日本院所有行心脏手术，且存活出院的患者，门诊或电话随访患者的生存情况至2010年2月28日。回顾性收集患者术前、术中、术后的临床及实验室资料，观察患者术后长期生存率及肾功能情况。应用Cox回归方程分析与患者长期生存相关的危险因素。结果共941例心脏手术患者，术后发生过AKI患者275例（29．2％），非AKI患者666例（70．8％）。在总共46．5个月（34．5，59．2）的随访过程中，术后发生过AKI的患者生存率显著低于非AKI患者（67．8％比85．6％，P〈0．01），且随着AKI严重程度的增加，生存率逐渐下降（AKIN1、2和3期患者的生存率分别为70．7％、62．3％和58．6％，P〈0．01）。AKI组中90．5％的患者出院时肾功能完全恢复至基线水平，但随访期间生存率仍显著低于非AKI组患者（69．6％比85．6％，P〈0．01）。Cox回归分析显示年龄增加（年龄每增加20岁，HR=2．238）、术前贫血（HR=1．625）、手术时间延长（每增加1h，HR=1．153）、AKI的发生及分期增加（每增加1期，HR=1.473）是患者长期预后不良的独立危险因素。随访结束时，AKI组患者的Set显著高于非AKI组（107．6μmol／L比83．0μmol／L，P=0．014）；AKI组中34．0％患者进入了CKD3～5期。出院后5年34.8％的AKI患者发生Scr翻倍。结论心脏手术后AKI是影响患者长期生存的独立危险因素，即使AKI后Scr值恢复到基线水平，长期的患者预后和肾脏预后仍然较差。

Objective To investigate the long-term prognosis and possible risk factors of acute kidney injury （AKI） following cardiac surgeries. Methods Clinical data of 941 patients undergoing open heart surgery from January 2004 to June 2007 were retrospectively analyzed. Survival and renal function of above patients were informed through telephone or clinic follow-up till February 2010. Long-term survival was analyzed using risk-adjusted Cox proportional hazards regression model. Results Of the 941 patients after cardiac surgery, 275 （29.2%） developed AK1 and 666（70.8%）did not. Survival was worse in patients with AKI（67.8% vs 85.6%,P〈0.01 ） and was proportional to its severity （AKIN 1, 2 and 3 stages： 70.7%, 62.3% and 58.6% ,P〈 0.01）. Although 90.5% of patients had complete renal recovery after AKI at discharge of hospital, they still had an increased risk for death during follow-up compared with patients without AKI （69.6% vs 85.6%,P〈0.01）. In the Cox proportional hazards regression model, age （HR=2.238）, anemia （HR=1.625）, prolonged operation time （HR=1.153）, AKI severity （HR=1.473） were independent risk factors for long-term prognosis after cardiac surgery. At the end of the follow-up, patients with AKI had statistically higher Scr than non-AKI patients （107.6 μmol/L vs 83.0 μmol/L, P=0.014）, and among those AKI patients, 34.0% progressed into CKD 3-5 stages, 34.8% developed double serum creatinine. Conclusions AKI is a risk factor for the long-term prognosis of cardiac surgery. Patients with complete renal recovery after AKI still has an increased risk for death and poor renal function compared with patients without AKI.