肝移植术后急性肾损伤的危险因素分析

Risk factors of acute kidney injury after liver transplantation

目的探讨影响肝移植术后急性肾损伤(AKI)的危险因素。方法回顾性研究2007年1月至2013年8月在中山大学附属第三医院肝移植中心行肝移植的300例患者临床资料。所有患者均签署知情同意书,符合医学伦理学规定。根据患者术后有否发生AKI分为AKI组和非AKI组。AKI组93例,其中男83例,女10例;年龄24～72岁,中位年龄48岁;非AKI组207例,其中男183例,女24例;年龄20～75岁,中位年龄48岁。观察两组患者住院期间病死率及AKI组不同分期患者的病死率。比较两组患者术前血清白蛋白(ALB)、血清肌酐(Scr)、肾小球滤过率(GFR)、终末期肝病模型联合血清钠(MELD-Na)评分、术中出血量、输血量、冷缺血时间、无肝期时间、手术时间,以及术后有否发生脓毒症等临床参数的差异,并进一步比较AKI组中不同分期患者临床参数的差异。正态分布资料比较采用t检验和单因素方差分析;非正态分布资料比较采用秩和检验;率的比较采用χ2检验。结果AKI组患者的住院期间病死率为12%(11/93),非AKI组为5%(10/207),差异有统计学意义(χ2=4.826,P<0.05)。AKI组患者肾损伤危险期、肾损伤期、急性肾衰竭期的病死率分别为3%(1/39)、15%(5/33)、33%(7/21),病死率呈逐渐上升趋势(χ2=10.806,P<0.05)。AKI的发生与术前ALB、Scr、GFR、MELD-Na评分,术中出血量、输血量有关(t=-11.7,t=7.88,t=-4.37,Z=7.1,Z=10.0,t=3.89;P<0.05)。AKI组术后脓毒症发生率为22%(20/93),非AKI组为13%(27/207),差异有统计学意义(χ2=4.157,P<0.05)。AKI组患者急性肾衰竭的发生与术前Scr、GFR、MELD-Na评分和术中出血、输血量有关(F=18.31,F=7.03,H=22.49,H=6.58,H=8.68;P<0.05)。结论肝移植术后AKI患者的病死率高,其发生与术前ALB、肾功能、MELD-Na评分和术中出血量、输血量有关,应加强围手术期监测,预防AKI的发生。

Objective To explore the risk factors of acute kidney injury （AKI） after liver transplantation （LT）. Methods Clinical data of 300 patients who underwent LT from January 2007 to August 2013 in Liver Transplantation Center, the Third Affiliated Hospital of Sun Yat-sen University were retrospectively analyzed. The informed consents of all participating subjects were obtained and the local ethical committee approval had been received. According to whether the patients developed AKI after operation, the patients were divided into AKI group （n=93, 83 males and 10 females, age： 24-72 years old, median age of 48 years old） and non-AKI group （n=207, 183 males and 24 females, age： 20-75 years old, median age of 48 years old）. The hospital mortality of two groups and mortality of patients with different stages in AKI group were observed. The differences of clinical parameters such as preoperative serum albumin （ALB）, serum creatinine （Scr）, glomerular filtration rate （GFR）, model for end-stage liver disease with serum sodium （MELD-Na） score, intraoperative blood loss and transfusion, cold ischemia time, anhepatic period, duration of operation and development of sepsis after operation of two groups were compared. And the differences of clinical parameters of patients with different stages in AKI group were further compared. The comparison of normal distribution data was performed using t test and one-way analysis of variance. The comparison of non-normal distribution data was performed using rank sum test. The comparison of ratio was performed using Chi-square test. Results The hospital mortality was 12% （11/93） in AKI group, and was 5% （10/207） in non-AKI group, where significant difference was observed （χ2=4.826, P〈0.05）. The mortality of patients in AKI group in risk stage, injury stage, failure stage were 3% （1/39）, 15% （5/33）, 33% （7/21） respectively with a gradual upward trend （χ2=10.806,P〈0.05）. The development of AKI was related with preoperative ALB, Scr, GFR, MELD-Na score, intraoperative blood loss and transfusion （t=-11.7, t=7.88, t=-4.37, Z=7.1, Z=10.0, t=3.89; P〈0.05）. The incidence of postoperative sepsis was 22% （20/93） in AKI group, and was 13% （27/207） in non-AKI group, where significant difference was observed （χ2=4.157, P〈0.05）. The development of acute kidney failure in AKI group was related with preoperative Scr, GFR, MELD-Na score, intraoperative blood loss and transfusion （F=18.31, F=7.03, H=22.49, H=6.58, H=8.68; P〈0.05）. Conclusions The mortality of patients with AKI after LT is high. The development of AKI after LT is related with preoperative ALB, renal function, MELD-Na score, intraoperative blood loss and transfusion. Perioperative monitoring should be enhanced to prevent AKI.