术后早期使用ACEI／ARB或利尿剂对老年心脏术后急性肾损伤发生的影响

Effect of early postoperative use of ACEI/ARB or diuretics on the incidence of acute kidney injury after cardiac surgery in elderly patients

【摘要】目的探讨老年心脏手术患者术后早期使用血管紧张素转换酶抑制剂／血管紧张素受体拮抗剂（ACEI／ARB）或利尿剂对术后发生急性肾损伤（AKI）的影响。方法收集2007年1月至2010年12月在广东省人民医院行体外循环（CPB）心脏手术的老年（年龄／〉60岁）患者的临床资料。观察终点为以术前最后一次血肌酐值为基线、且符合RIFLE（危险、损伤、衰竭、肾功能丧失、终末期肾病）标准诊断的AKI。采用logistic回归分析确定心脏术后AKI的独立危险因素。结果共入组618例患者，其中76例（12．3％）术后早期使用ACEI／ARB，491例（79．4％）术后早期使用利尿剂；394例（63．8％）术后发生AKI。术后早期使用ACEI／ARB组AKI的发生率低于未使用ACEI／ARB组（46．1％比66．2％，P〈0．001）；术后早期使用利尿剂组AKI的发生率明显低于未使用利尿剂组（57．0％比89．8％，P〈zO．001）。Logistic回归分析显示，术后早期使用ACEI／ARB[优势比（OR）----0．131，95％可信区间（95％口）为0．033—0．517，P=0．004]或利尿剂（OR-=0．149，95％C1为0．076—0．291，P〈0．001）是具有肾脏保护作用的独立因素。结论术后早期使用ACEI／ARB或利尿剂可降低老年心脏手术患者术后发生AKI的风险。

Objective To explore the influence of early postoperative use of angiotensin converting enzyme inhibitors/angiotensin receptor blockers （ACEI/ARB） or diuretics on acute kidney injury （AKI） after cardiac surgery in elderly patients. Methods Data from elderly patients （age 960 years old） who underwent cardiac surgery with extracorporeal circulation in Guangdong General Hospital between January 2007 and December 2010 were analyzed in this retrospective research. The primary endpoint was AKI as diagnosed according to the serum creatinine criteria of RIFLE （risk, injury, failure, loss, end stage renal disease）. The baseline serum creatinine was defined as the latest serum creatinine level before cardiac surgery. Multivariate analysis by logistic regression was used to obtain the independent risk factors for AKI. Results Among 618 elderly patients, 76 （ 12.3% ） patients received ACEI/ARB during early postoperative period, 491 （79.4%） patients were given diuretics during early postoperative period, and postoperative AKI occurred in 394 （63.8%） patients. The incidence of AKI was 46.1% in patients who received early postoperative ACEI/ARB, and 66.2% in patients who did not （P 〈0.001）. Patients who received diuretics postoperatively were less likely to suffer from AKI compared with patients who did not （57.0% vs. 89.8%, P〈0.001 ）. After adjustment of other potential factors of postoperative AKI, logistic regression analysis showed that early postoperative use of ACEI/ARB codds ratio （OR）=0.131, 95% confidence interval （95%CI） 0.033-0.517, P= 0.0041, and early postoperative use of diuretics （OR =0.149, 95% CI 0.076-0.291, P 〈0.001 ） independently predicted the occurrence of AKI. Conclusion Early postoperative use of ACEI/ARB or diuretics is associated with a lower incidence of AKI after cardiac surgery with extracorporeal circulation in elderly patients.