容量过负荷程度对心脏手术后急性肾损伤接受肾脏替代治疗患者肾脏预后的影响

Effect of fluid overload on renal outcome in acute kidney injury patients receiving renal replacement therapy after cardiac surgery

目的 探讨容量过负荷（FO）程度对心脏手术后急性肾损伤（AKI）接受肾脏替代治疗（RRT）患者总体预后和肾脏预后的影响,以进一步指导心脏手术后AKI患者的液体管理策略。方法 收集2009年1月—2014年4月间接受心脏手术后发生AKI并进行RRT（AKI-RRT）的患者143例,存活（存活组）51例（35.7%）,死亡（死亡组）92例（64.3%）。绝对FO=总入液量-总出液量,相对FO（%FO）=（总入液量-总出液量）/基础体重×100%。根据患者RRT开始前%FO程度分为RRT前-10%-〈0组、0-〈10%组、10%-〈20%组,根据RRT结束时%FO程度分为RRT后-10%-〈0组、0-〈10%组、10%-〈20%组。结果 死亡组与存活组间心脏外科术前、术中、术后相关因素的差异均无统计学意义（P值均〉0.05）。死亡组手术开始至RRT结束、入ICU至RRT结束时的FO和%FO均显著高于存活组（P值均〈0.05）。RRT前-10%-〈0组、RRT前0-〈10%组的肾功能完全恢复率均显著高于RRT前10%-〈20%组（P值均〈0.05）,3组间院内病死率、肾功能未恢复率、肾功能部分恢复率的差异均无统计学意义（P值均〉0.05）。RRT后-10%-〈0组、RRT后0-〈10%组的肾功能完全恢复率均显著高于RRT后10%-〈20%组（P值均〈0.05）,RRT后-10%-〈0组又显著高于RRT后0-〈10%组（P〈0.05）;RRT后-10%-〈0组、RRT后0-〈10%组的院内病死率均显著低于RRT后10%-〈20%组（P值均〈0.05）,RRT后-10%-〈0组又显著低于RRT后0-〈10%组（P〈0.05）;3组间肾功能未恢复率、肾功能部分恢复率的差异均无统计学意义（P值均〉0.05）。结论 FO增加心脏手术后AKI-RRT患者的死亡风险,RRT前后的FO不利于肾功能的完全恢复。应进一步重视心脏手术后AKI患者的容量平衡。

Objective To explore the effect of fluid overload （FO） on clinical outcome and renal prognosis in acute kidney injury （AKI） patients receiving renal replacement therapy （RRT） after cardiac surgery. Methods A total of 143 patients who suffered from AKI and received RRT after cardiac surgery from January 2009 to April 2014 were enrolled in this retrospective study. There were 51 survivors （35. 7%） and 92 deaths （64.3%）. The absolute FO = Fluid in- Fluid out. Percent fluid overload （% FO） = （Fluid in- Fluid out）/ admission weight x 100%. Results There was no significant difference in pre-, intra- or post-operative correlation factors between survivor group and death group .（all P〉 0. 05）. The absolute FO and % FO from surgery to the end of RRT, from intensive care unit （ICU） admission to the end of RRT in the death group were significantly higher than those in the survivor group （both P〈0.05）. According to % FO before RRT, the patients were divided into groupA （%F0.. -10%-d0）, groupB （%FO： 0-〈10%）, and groupC （%F0.. 10%-〈 20%）. According to %FO after RRT, the patients were divided into group D （%FO： - 10% -d0）, group E （%FO： 0-〈10%）, and group F （%FO： 10% -〈20%）. The rate of complete renal recovery of group A and B was significantly higher than that in group C （both P〈0.05）, but there were no significant differences in in-hospital mortality, renal no-recovery, or partial renal recovery between the three groups （all P〉0.05）. Compared to those in group F, the rate of complete renal recovery of group D and E was significantly increased and the in- hospital mortality was significantly decreased （all P〈0. 05） ; and there were significant differences in the complete renal recovery and in-hospital mortality between group D and E （both P〈0. 05）; but there were no significant differences in renal no-recovery or partial renal recovery between the three groups （both P〉0.05）. Conclusion Fluid overload will increase the risk of death in AKI-RRT patients after cardiac surgery. Fluid overload before and after RRT may reduce the complete renal recovery in RRT. More attention should be paid to the control of fluid balance among AKI patients after cardiac surgery.