轻度急性肾损伤对体外循环心脏手术患者 预后的影响：来自5 823例病例分析的结果

Effect of stage 1 acute kidney injury on the prognosis of patients underwent cardiopulmonary bypass cardiac operation：an analysis results from 5 823 patients

目的：探讨1期急性肾损伤（AKI）对体外循环（CPB）心脏手术患者预后的影响。方法采用回顾性分析方法，选择2013年7月1日至2015年12月31日北京安贞医院行CPB心脏手术治疗且年龄≥18岁的患者。根据改善全球肾脏病预后组织（KDIGO）指南中血肌酐（SCr）的标准，纳入1期AKI和非AKI患者作为研究对象；分析两组患者围手术期临床资料，随访患者预后并绘制Kaplan-Meier生存曲线，采用Cox回归模型分析影响CPB心脏手术治疗的1期AKI患者预后的危险因素。结果共纳入5823例患者，其中AKI患者1285例（1期AKI组998例，占总AKI患者的77.67%）；非AKI组4538例。两组患者平均随访时间为（23.13±12.28）个月。与非AKI患者比较，1期AKI患者30d病死率明显升高〔4.00%（40/998）比0.40%（18/4538）， P＜0.01〕。Kaplan-Meier生存曲线显示，1期AKI组患者累积存活率明显低于非AKI组（log-rank＝51.989，P＜0.001）；进一步亚组分析显示，术后SCr未恢复的1期AKI患者累积存活率明显低于SCr恢复的1期AKI患者（log-rank＝43.580，P＝0.000）。Cox多因素分析显示，1期AKI〔危险比（HR）＝2.725，95%可信区间（95%CI）＝1.810～4.230，P＝0.000〕及术中CPB时间延长（HR＝1.013，95%CI＝1.001～1.017，P＝0.000）、合并冠心病（HR＝1.046，95%CI＝1.010～1.063，P＝0.005）和糖尿病（HR＝1.060，95%CI＝1.010～1.090，P＝0.002）是导致CPB心脏手术患者死亡的独立危险因素。结论1期AKI是CPB心脏手术患者发生AKI的主要类型，也是影响该类患者长期预后的独立危险因素。

Objective To investigate the effect of stage 1 acute kidney injury （AKI） on the prognosis of patients underwent cardiopulmonary bypass （CPB） cardiac operation. Methods A retrospective analysis was conducted. All patients aged ≥ 18 years who underwent cardiac operation with CPB admitted to Beijing Anzhen Hospital from July 1st, 2013 to December 31st, 2015 were enrolled. According to the standard of serum creatinice （SCr） of Kidney Disease Improving Global Outcomes （KDIGO） criteria, the AKI patients with stage 1 and non-AKI patients were served as the research objects. Perioperative clinical data of two groups were collected, and the prognosis was recorded during follow up to draw the Kaplan-Meier survival curve. Cox regression model was used to analyze the risk factors of prognosis in patients with stage 1 AKI experienced CPB during cardiac operation. Results A total of 5 823 patients were enrolled, of which 1 285 patients with AKI, and those in stage 1 was 998, accounting for 77.67% of total AKI patients; and 4 538 in non-AKI group. The mean follow-up period among survivors was （23.13±12.28） months. Compared with non-AKI patients, 30-day mortality of patients with stage 1 AKI was significantly increased [4.00% （40/998） vs. 0.40% （18/4 538）, P〈 0.01]. It was showed by Kaplan-Meier survival analysis that the cumulative survival rate of patients with stage 1 AKI was significantly lower than that of non-AKI patients （log-rank = 51.989, P 〈0.001）. It was showed by further subgroup analysis that the cumulative survival rate of patients with stage 1 AKI without serum creatinine （SCr） recovery was significantly lower than that of patients with SCr recovery from stage 1 AKI （log-rank = 43.580, P = 0.000）. It was showed by Cox multivariate analysis that stage 1 AKI [hazard ratio （HR） = 2.725, 95% confidence interval （95%CI） = 1.810-4.230, P = 0.000] and prolonged CPB in patients undergoing cardiac operation （HR = 1.013, 95%CI = 1.001-1.017, P = 0.000）, combined with coronary heart disease （HR = 1.046, 95%CI = 1.010-1.063, P = 0.005） and diabetes mellitus （HR = 1.060, 95%CI = 1.010-1.090, P = 0.002） were independent risk factors of death in patients undergoing CPB during cardiac operation. Conclusion Stage 1 AKI is the main stage of AKI and it is independently related to all-cause mortality in patients underwent cardiovascular operation using CPB.