急性A型主动脉夹层患者术后急性肾损伤的危险因素

The analysis on risk factors of postoperative acute renal injury in acute Stanford type A aortic dissection

目的探讨StanfordA型急性主动脉夹层动脉瘤外科手术后发生急性肾损伤（AKI）的围术期危险因素。方法2010年1月至2011年12月，137例StanfordA型急性夹层动脉瘤患者施行外科手术。其中男106例，女31例，年龄（46．8±13．1）岁，体质量（69．9±18．0）kg。以2005年急性肾损伤网络工作小组制定的AKIN诊断标准为术后急性肾损伤的诊断标准。全组患者均在体外循环下施行外科手术，其中深低温停循环＋选择性脑灌注下施行大血管手术120例，54例行全主动脉弓置换，66例行右半弓置换。术后维持动脉平均压在80～90mmHg（1mmHg=0．133kPa），及时补充血容量，积极纠正低氧血症及低蛋白血症。对于经内科药物治疗后仍尿少、无尿或血肌酐值持续上升〉500μmol／L者，予行肾脏替代治疗。结果术后早期死亡12例，病死率8．74％。术后第1天发生AKI者76例（55．47％），其中AKIⅠ期38例（27．7％），Ⅱ期21例（15．3％），Ⅲ期17例（12．4％）。发生AKI者中36例出现急性肾功能衰竭（acute renalfailure，ARF），发生率为26．3％，其中34例接受肾脏替代治疗。单因素分析提示术前肌酐、全弓置换术、体外循环时间、术日浓缩红细胞的输注量是术后发生ARF的危险因素，以logistic回归进行多因素分析提示，全弓置换术以及术前肌酐异常是术后AFR的独立危险因素。结论全弓置换术以及术前肌酐异常是急性A型夹层术后AFR的独立危险因素。

Objective To analyze the risk factors of postoperative acute renal injury （AKI） for acute Stanford type A aortic dissection in 137 cases. Methods From January 2010 to December 2011, 137 patients with acute Stanford type A aortic dissection were received surgical operations in our hospital. There were 106 males and 31 females with their mean age of（46. 8 ± 13.1 ） years and mean weight of （69.9 ± 18.0 ） kg. The postoperative acute renal injury diagnosis was according to AKIN diagnosis standard of acute kidney injury network working group in 2005. All patients were received surgical repair with car-diopubnonary bypass, including 120 patients with deep hypothermic circulatory arrest and selective cerebral perfusion. Among them, there were 54 cases with total arch replacement and 66 with right half arch replacement. The postoperative managements were include control the patients＇ mean arterial blood pressure at 80 to 90 mmHg （l mmHg = 0. 133 kPa）, supplement the blood volume timely, and correction of hypoxia and hypoproteinemia. The patients were received renal replacement therapy if still oliguria after medical treatments, or their blood creatinine raising continually more than 500 μmol/L. Results A total of 12 patients died in hospitalization with a total in-hospital mortality of 8.74% （ 12/137 ）. 76 cases had AKI in the first day after operations, including 38 cases （27.7%） with stage Ⅰ and 21 cases （ 15.3% ） with stage Ⅱ and 17 cases （ 12.4% ） with stage Ⅲ. There were 36 patients have acute renal failure （ARF） with morbility of 26.3% （36/137）, and 34 patients among them were received renal replacement therapy. Single factor analysis showed that preoperative creatinine, total arch replace-ment, cardiopulmonary bypasstime, intraoperative day transfusion of concentrated red cells are risk factors of ARF. Logistic re-gression was used for multivariate analysis showed that total arch replacement and preoperative creatinine abnormalities are inde-pendent risk factors for postoperative AFR. Conclusion Total arch replacement and preoperative creatinine abnormalities were independent risk factors of AFR for acute type A dissection after operation.