心外科术后急性肾损伤实施连续性肾替代治疗的预后分析

Prognostic analysis of acute kidney injury after cardiac surgery with continuous renal replacement therapy

目的 心脏外科术后急性肾损伤（CSA-AKI）实施连续性肾替代治疗（CRRT）的患者预后分析. 方法 回顾首都医科大学附属北京安贞医院2013年1月-2013年12月实施CRRT的114例CSA-AKI患者的临床资料.结果 114例患者中男性73例,年龄21-83岁,平均55.8±13.1岁.通过首都医科大学附属北京安贞医院创建的“成人心脏外科手术后急性肾损伤的预警评分系统”进行评分,≥12分的高危患者占64.9％ （73/114）,平均12.9±3.3分.开始CRRT的时机在术后2-144h,中位数26.5 h （20.0,68.0）,CRRT的总治疗时间24-692h,中位数77 h （36.0,148.5）.114例患者中死亡63例（55.3％）、肾功能恢复36例（31.6％）、进入维持性肾替代治疗15例（13.1％）.死亡组63例患者与存活组51例患者在年龄、预警评分、CRRT的总时间存在显著性差异（P＜0.05）;死亡组患者接受联合手术机率（17.5％比3.9％）及低心排综合征等并发症的发生率明显多于存活组（P＜0.05）;114例患者中早期实施CRRT的54例患者比晚期CRRT的60例患者有显著的肾功能恢复率（P＜0.05）.多元Logistic回归分析显示,术后肺机械通气＞24h、术后低血压是CSA-AKI实施CRRT患者死亡的独立危险因素（P＜0.05）. 结论 CSA-AKI的死亡率非常高,尤其接受肾替代治疗的患者.预警评分能预测AKI的发生及死亡的风险.术后肺机械通气＞24h、术后低血压是死亡的独立危险因素.患者高龄、接受联合手术、术后发生低心排综合征等因素也与其死亡有关.早期实施CRRT能促进CSA-AKI患者肾功能恢复.

Objectives To analyze the prognosis of patients with cardiac surgery associated-acute kidney injury （CSA-AKI） requiring continuous renal replacement therapy （CRRT）. Methods Clinical data of 114 patients with CSA-AKI receiving CRRT from Jan. 2013 to Dec. 2013 in Beijing Anzhen Hospital of Capital Medical University were analyzed. Results In the 114 patients, 73 patients were male with the mean age of 55.84±13.1 years （21 to 83 years）. According to the risk prediction score system we established to predict post- operative AKI, 64.9% were high-risk patients with the score of ≥12 points （mean 12.9±3.3）. The initiation of CRRT was 2-144 h after the surgery with the median of 26.5 h （20.0, 68.0）. CRRT totally lasted 24-692 h with the median of 77 h （36.0, 148.5）. In the 114 patients, 63 patients （55.3%） died, renal function recovered in 36 patients （31.6%）, and 15 patients （13.1%） required maintenance renal replacement therapy. There were statistical significance in age （61.4±13.4 vs. 56.5±12.2 years）, risk prediction score （14.4±2.9 vs. 11.2-2.8） and CRRT duration （54.0 vs. 96.0 h） between death group （n=63） and survival group （n=51）. Combined surgery and important complications such as low cardiac output syndrome were more prevalent in death group than in survival group （P〈0.05）. Forty-four patients treated with CRRT at early or middle AKI stage （within 24 h after surgery or urine output ≤30 ml/h for less than 12 h） had higher renal ftmction recovery rate than the 60 patients treated with CRRT at late AKI stage （urine output ≤ 30 ml/h for 〉24 h） （P〈0.05）. Multivariate logistic regression showed that postoperative mechanical ventilation time 〉24h （0.09; 95% C/, 0.02-0.33）, postoperative hypotension （0.081; 95% CI, 0.02-0.28） were the independent risk factors for death in patient with CSA-AKI （P〈0.05）. Conclusion CSA-AKI is accompanied by a very high mortality, especially in those requiring renal replacement therapy. The risk prediction score can be used to predict the occurrence of AKI and risk of death. Postoperative mechanical ventilation for more than 24 h and postoperative hypotension are the independent risk factors for death. Older age, combined operation and low cardiac output syndrome after operation are also related to death. Early implementation of CRRT is useful for renal fimction recovery in CSA-AKI patients.