低心排综合征是行肾脏替代治疗的心脏手术后急性肾损伤患者死亡的主要危险因素

Low cardiac output syndrome is the main death risk factor of acute kidney injury patients with renal replacement therapy after cardiac surgery

目的分析接受肾脏替代疗法(RRT)的心脏手术相关急性肾损伤(CS-AKI)患者的死亡原因及死亡危险因素。方法收集2002年1月—2011年4月在复旦大学附属中山医院心外科接受心脏手术后发生CS-AKI且接受RRT的患者临床资料,终点事件为出院时转归情况。结果共纳入172例患者,男117例,女55例,年龄18～83岁,平均年龄为(55±14)岁。死亡患者75例(43.6%,75/172),直接死亡原因依次为心力衰竭(48.0%)、呼吸功能衰竭(22.7%)、血液系统功能衰竭(9.3%)、脓毒症(8.0%)、肾衰竭(6.7%)、肝衰竭(5.3%)。所有死于心力衰竭患者术后均发生低心排综合征(LCOS)。死亡组术后LCOS发生率为56.0%(42/75),显著高于存活组的19.6%(19/97,P<0.01),死亡组术后早期及重症监护病房(ICU)住院期间容量过负荷发生比例分别为45.3%(35/75)、68.0%(51/75),均显著高于存活组的21.6%(21/97)、46.4%(45/97,P值均<0.01)。Logistic单因素回归分析显示,LCOS(OR=5.2,95%CI为2.7～10.3)、住ICU期间容量过负荷(OR=2.0,95%CI为1.1～3.8)、早期容量过负荷(OR=3.0,95%CI为1.5～5.8)、脓毒症(OR=4.3,95%CI为1.8～10.1)、术中心肺旁路时间(每增加1h,OR=1.005,95%CI为1.001～1.010)均为接受RRT的CS-AKI患者术后30d死亡的危险因素(P值分别<0.05、0.01)。Logistic多因素回归分析显示,仅LCOS为接受RRT的CS-AKI患者术后30d死亡的独立危险因素(OR=4.2,95%CI为2.0～8.5,P<0.01)。结论接受RRT的CS-AKI患者的直接死亡原因主要为心力衰竭,术后LCOS是死亡的主要危险因素,需及早防治。

[Abstract] Objective To analyze the death cause and risk factor for the patients with acute kidney injury （AKI） requiring renal replacement therapy （RRT） after cardiac surgery. Methods Clinical data of the patients who developed AKI and received RRT after cardiac surgery from January 2002 to April 2011 in Zhongshan Hospital were retrospectively analyzed. Cause of death was classified according to Montgomery diagnostic standard. Results A total of 172 patients were enrolled in this study. There were 117 males and 55 females with an average age of （55＋_ 14） years （ranged 18 to 83 years）. The overall mortality was 43.6% （n = 75）. Death causes included heart failure （48%）, respiratory failure （22.7%）, hematological failure （9.3%）, severe sepsis （8.0%）, renal failure （6.7%）, and liver failure （5.3%）. The patients who died of heart failure had low cardiac output syndrome （LCOS） after surgery. The incidence of LCOS in death group was significantly higher than that in survivor group （56.0 % vs. 19.6 %, P〈0.01 ）. The percentage of fluid overload in death group was significantly higher than that in survivor group at early stage after surgery and in ICU （45.3% [34/75] vs. 21.6% [21/97], 68.0%[51/75] vs. 46.4%[45/97], P〈0.01）. Single Logistic regression analysis showed that LCOS （OR = 5.2, 95% CI, 2.7 - 10.3）, fluid overload in IOU （ OR = 2.0, 95% CI ： 1.1 - 3.8） and at early stage after surgery （OR= 3. 0, 95% CI： 1. 5- 5.8）, severe sepsis （OR = 4. 3, 95% Cl= 1. 8-- 10. 1）, and intraoperative cardiopulmonary bypass time （OR -- 1.005, 95% CI= 1. 001 - 1. 010） were risk factors of death in AKI-RRT patients after cardiac surgery （P〈0.05, 0.01）. Multivariate Logistic regression analysis showed that LCOS was the only independent risk factor of death （OR=4.2, 95%CI; 2.0-8.5, P〈0.01）. Conclusion Heart failure is the main cause of death for the patients who developed AKI and required RRT after cardiac surgery. LCOS is the predominant independent risk factor for death. It is recommended that cardiac pump function should be improved after surgery. （Shanghai Med J, 2013, 36= 204-208）