终末期肾病患者行开胸心脏外科手术的临床分析

Cardiac surgery in end stage renal disease patients

目的分析行开胸心脏外科手术的终末期肾病(End-stage renal disease,ESRD)患者的临床特征及转归,探讨患者围手术期肾脏替代治疗的方式。方法:对北京大学第一医院在2004年9月至2011年1月期间行开胸心脏手术的终末期肾脏病病例进行单中心回顾性分析。结果共有16例(ESRD)患者行开胸心脏外科手术。8例患者行冠状动脉搭桥术(coronary artery bypass grafting,CABG),5例患者行瓣膜置换术,3例患者同时行CABG和瓣膜置换术。14例患者术后6.7±5.1h开始行床旁持续性肾脏替代治疗(延长低效血液透析滤过)(4.83±2.95)次,平均每次治疗时间(9.71±3.75)h,单次治疗总置换液量(33.0±11.6)L。手术当日行无肝素治疗,术后第2d根据病情选择抗凝方式和药物。病情稳定后转为常规血液透析/滤过。患者住院死亡率25%(4/16),死亡原因分别为围手术期心肌梗死(1例)、心包填塞(1例)和低排综合征(2例)。存活的12例患者术后随访33个月(3-65个月),3例患者分别因肝癌、脑出血和心力衰竭死亡。结论经过强化肾脏替代治疗和其他综合支持治疗,ESRD患者经过充分准备可以耐受心脏外科开胸手术并达到长期存活;心血管病变和外科手术复杂的高龄患者围手术期死亡率较高。

Objectives To investigate the clinical characteristics and outcome of end-stage renal disease （ESRD） patients undergoing cardiac surgery,and to explore the optimal protocol for peri-operative renal replacement therapy.Methods A single-center retrospective analysis was conducted in dialysis patients who were managed with coronary artery bypass grafting （CABG） and/or cardiac valve replacement （VR） during the period between September,2004 and January,2011.Results Sixteen patients who met our inclusion criteria were studied.CABG was performed in 8 patients,VR in 5 patients,and CABG＋ VR in 3 patients.Extended low-efficiency hemodiafiltration commenced 6.7±5.1 hours after operation.Every hemodiafiltration session lasted 9.71±3.75 hours and consumed 33.0±11.6 liters of replacement fluid.The average hemodiafiltration sessions were 4.83±2.95 times for a patient before they were converted to regular hemodialysis or hemodiafiltration.The in-hospital mortality was 25% （4/16）,and the causes of death were peri-operative myocardial infarction （one patient）,pericardial temponade （one patient） and low output syndrome （2 patients）.Survival patients were followed up for 33 （3～65） months,and during that period 3 patients died of hepatic carcinoma,cerebral hemorrhage or heart failure.Conclusions Dialysis-dependent patients undergoing cardiac surgery could achieve better successful rate with long-term survival when intensive peri-operative renal replacement therapy was used.In-hospital mortality was high in elder patients managed with CABG and VR simultaneously.