1371例急性心肌梗死后急性肾损伤患者的临床分析

Clinical analysis of 1 371 patients with acute kidney injury after acute myocardial infarction

目的 探讨急性心肌梗死（AMI）患者急性肾损伤（AKI）的危险因素.方法 回顾性分析2008年12月1日至2012年12月31日在苏州大学附属第三医院诊断急性心肌梗死患者（共计1 371例）的临床资料,根据KDIGO指南推荐标准定义AKI.根据是否发生AKI将患者分成AKI组和非AKI组;根据AKI发生的时机分为保守治疗AKI组及保守治疗非AKI组,冠脉造影术（coronary angiography,CAG）后AKI组及CAG术后非AKI组,及冠脉搭桥术（coronary artery bypass grafting,CABG）后AKI组及CABG术后非AKI组.AKI相关危险因素的分析采用单因素、多因素Logistic回归.结果 AMI后410例患者（29.9％）并发AKI,其中保守治疗、CAG后、CABG后AKI的患病率依次为34.8％ （228/656）、24.5％ （168/686）、57.7％ （30/52）.住院期间共计死亡107例,病死率为7.8％;AKI患者的病死率较非AKI组显著增高（17.1％比3.9％,x2=68.0,P＜0.001）.多因素Logistic回归分析结果示保守治疗AKI组,基线eGFR下降（OR=2.049,95％ CI：1.246～3.370）、空腹血糖（FBG）升高（OR=1.070,95％CI：1.018～1.124）、利尿剂（OR=1.867,95％CI：1.220～2.856）和心梗KillipⅣ级（OR=1.362,95％CI：1.059～3.170）是AKI患病的独立危险因素（均P＜ 0.05）,入院时舒张压（DBP）增高（OR=0.986,95％CI：0.974～0.998）是AKI患病的保护性因素（P＜ 0.05）;CAG术后组,基线eGFR下降（OR=2.371,95％CI：1.500 ～ 3.747）、空腹血糖升高（OR=1.009,95％CI：1.005～1.012）、利尿剂（OR=1.674,95％CI：1.042～2.690）、术中低血压（OR=2.276,95％CI：1.324 ～ 3.575）和急性感染（OR=1.678,95％CI：1.023 ～ 2.754）是AKI患病的独立危险因素（均P＜ 0.05）;CABG术后组,基线eGFR下降（OR=2.246,95％CI：1.340～3.981）、空腹血糖升高（OR=1.059,95％CI：1.018～ 1.124）、利尿剂（OR=1.723,95％CI：1.122～2.650）和术后低心排血量综合征（OR=2.331,95％CI：1.277～3.286）是AKI患病的独立危险因素（均P＜ 0.05）.结论 住院AMI患者AKI的发生率、病死率均较高.基础肾功能减退、空腹血糖升高及利尿剂的应用为AMI患者并发AKI的独立危险因素.

Objective To investigate the risk factors of acute kidney injury （AKI） in patients after acute myocardial infarction （AMI）.Methods A total of 1 371 adult patients diagnosed AMI in the First People＇s Hospital of Changzhou from January 2008 to December 2012 were analyzed retrospectively.AKI was defined according to the 2012 KDIGO AKI criteria.Based on the occurrence of AKI,the patients were divided into AKI group and non-AKI group.According to the AKI timing,the patients were divided into subgroups including conservative treatment groups,coronary angiography （CAG） groups and coronary artery bypass grafting （CABG） groups,respectively.Related risk factors of AKI were analyzed by univariate and multivariate logistic regression.Results Of the 1 371 patients,410（29.9％） developed AKI.Compared to the non-AKI group,in-hospital mortality increased significantly in the AKI group （17.1％ vs 3.9％,x2=68.0,P ＜ 0.001）.Multifactor retrospective analysis showed that decreased baseline eGFR （OR=2.049,95％ CI：1.246-3.370）,increased fasting plasma glucose（FPG） （OR=1.070,95％CI：1.018-1.124）,diuretics （OR=1.867,95％CI：1.220-2.856） and Killip class 4 status （OR=1.362,95％ CI：1.059-3.170） were all independent risk factors of AKI,while increased DBP on admission was a protective factor （OR=0.986,95％ CI：0.974-0.998） for the conservative management group.Decreased baseline eGFR （OR=2.371,95％CI：1.500-3.747）,increased FPG（OR=1.009,95％CI：1.005-1.012）,diuretics （OR=1.674,95％CI：1.042-2.690）,intraoperative hypotension （OR=2.276,95％ CI：1.324-3.575） and acute infection （OR=1.678,95％CI：1.023-2.754） were independent risk factors of AKI for the CAG group.Decreased baseline eGFR （OR=2.246,95％CI：1.340-3.981）,increased FPG （OR=1.059,95％CI：1.018-1.124）,diuretics （OR=1.723,95％CI：1.122-2.650）,and low cardiac output syndrome after operation （OR=2.331,95％ CI：1.277-3.286） were independent risk factors of AKI for CABG group.Conclusions AKI is a common complication and associated with increased mortality after AMI.Decreased baseline renal function,increased FPG and diuretics were common independent risk factors of AKI after AMI.