非体外循环冠状动脉旁路移植术后肾损伤风险因素的分析

Risk factors of renal injury after off-pump coronary artery bypass grafting

目的：探讨非体外循环冠状动脉移植术（OPCABG）术后急性肾损伤（AKI）的风险因素。方法：回顾性分析我院2012年6月至2013年5月,1 050例OPCABG手术患者的临床资料。根据术后肾功能状况,分为AKI组139例（13.2%）和对照组,比较两组围术期相关因素的差异,应用Logistic回归分析OPCABG术后AKI的风险因素。结果：高龄、代谢综合征、陈旧性心肌梗死、急诊手术、明显外周血管粥样狭窄、左心室低射血分数（35%~40%）患者的比例,AKI组明显高于对照组;术前C反应蛋白（CRP）、胱抑素C水平,AKI组明显高于对照组;冠状动脉造影与外科手术的时间间隔,AKI组明显短于于对照组;术前规律应用他汀药物患者比例,AKI组明显低于对照组;术中心血管活性药物（去甲肾上腺素和肾上腺素）用量、术中目标冠状动脉吻合总时间,AKI组明显高于对照组;术中因冠状动脉弥散狭窄无法完全再血管化、术中及术后主动脉内球囊反搏（IABP）、术后急性心肌梗死患者比例、平均呼吸机辅助时间,AKI组明显高于对照组;术后液体补给容量,AKI组明显低于对照组。Logistic多因素回归分析显示,高龄（OR=2.55;95%CI：1.34~4.45;P〈0.01）、代谢综合征（OR=2.35;95%CI：1.42~4.76;P〈0.01）、术前高CRP水平（OR=2.24;95%CI：1.31~4.46;P=0.01）、术前高胱抑素C水平（OR=2.54;95%CI：2.11~5.36;P〈0.01）、急诊手术（OR=3.23;95%CI：2.22~6.76;P〈0.01）、明显外周血管粥样狭窄（OR=1.67;95%CI：1.21~4.06;P=0.04）、左心室低射血分数（OR=4.12;95%CI：2.26~7.76;P〈0.01）、术前短时间冠状动脉造影（OR=1.75;95%CI：1.34~3.76;P=0.03）、术前未规律应用他汀药物（OR=1.81;95%CI：1.37~3.96;P=0.03）、无法完全再血管化（OR=3.05;95%CI：2.21~5.39;P〈0.01）、术后急性心肌梗死（OR=4.12;95%CI：3.54~8.09;P〈0.01）、术中及术后IABP辅助（OR=3.23;95%CI：2.34~6.19;P〈0.01）为术后肾损伤的风险因素。结论：术前对比剂等肾毒性物质加重肾脏负担,他汀类药物一定程度提供保护作用;高龄、术前较差的机体代谢状况、慢性肾功能受损,预示肾功能储备下降;术前应激状态、术中心肌供血改善不足、围术期低下的心肌收缩状态,加重了肾脏损害或导致肾脏损害难以恢复。

Objective： To investigate the risk factors of acute kidney injury in patients undergoing offpump coronary artery bypass grafting（ OPCABG）. Methods： Clinical data of 1050 cases undergoing OPCABG in our hospital from June 2012 to May 2013 was retrospectively analyzed. According to postoperative renal function,139 patients（ 13. 2%） were assigned to AKI group and the other were assigned to control group. Compared the difference between the 2 groups,and logistic regression analysis was used to analyze the risk factors of AKI after OPCABG. Results： The proportion of patients with advanced age,metabolic syndrome,old myocardial infarction,emergency operation,significant peripheral vascular atherosclerotic,low left ventricular ejection fraction（ 35%-40%） in AKI group was significantly higher than that in control group; preoperative C-reactive protein（ CRP） and cystatin C levels in AKI group were significantly higher than that in control group; the time interval between coronary angiography and surgical operation in AKI group was significantly shorter than that in control group; the proportion of patients with preoperative regular use of statins in AKI group was significantly lower than that in control group; the dosage of vasoactive drugs（ norepinephrine and epinephrine） used intraoperatively and the total time of coronary artery anastomosis were significantly higher in patients with AKI; the ratios of incomplete revascularization attributed to diffuse coronary stenosis,perioperative intra aortic balloon pump（ IABP）,and acute myocardial infarction was significantly higher in AKI group; the duration of ventilation in AKI group was significantly longer than that in control group; the postoperative capacity supply in AKI group was significantly lower than that in control group. Logistic multivariate regression analysis showed that advanced age,metabolic syndrome,preoperative high CRP and cystatin C level,emergency surgery,significant peripheral vascular atherosclerotic,low left ventricular ejection fraction,preoperative short interval of coronary angiography,postoperative acute myocardial infarction,preoperative no application of statin,incomplete revascularization and perioperative IABP were independent risk factors for renal injury. Conclusion： Contrast agent could increase burden on kidney,and preoperative statins could provide protection to some extent. Advanced age,preoperative poor metabolization,and chronic renal damage indicated decline in renal reserve. Preoperative stress state,insufficient myocardial revascularization,and poor postoperative myocardial contractility aggravated kidney damage or made it difficult to recover.