巢式病例对照研究非心血管手术后急性肾损伤危险因素

Risk factors analysis of acute kidney injury after noncardiac surgeries： a nested case-control study

目的 探索非心血管手术术后发生急性肾损伤（acute kidney injury,AKI）的发病率,采用巢式病例对照研究进行危险因素分析预测. 方法 回顾性分析2012年1月～2014年10月19 132例非心血管手术病例资料,依据全球改善肾脏病预后组织（kidney disease improving global outcomes,KDIGO）指南,以血肌酐的改变为标准进行术后AKI诊断.术后血肌酐值较术前升高达到AKI诊断标准的病例28例（病例组）,采用巢式病例对照研究方法,按1∶6匹配同期同类未发生AKI的手术病例168例作为对照组,探讨年龄、性别、BMI、高血压、糖尿病、术前使用血管紧张素转化酶抑制剂（angiotension converting enzyme inhibitors,ACEI）/血管紧张素Ⅱ受体拮抗剂（angiotensin receptor blockers,ARB）类药物、低蛋白血症、术中低血压等因素对术后AKI的影响. 结果 19 132例非心血管手术患者中,28例（0.146％）发生了术后AKI.发生AKI的28例病例手术类型分别为：14例（50％）消化道手术,6例（22％）腹腔脏器手术,2例（7％）妇产科手术,2例（7％）泌尿外科手术,2例（7％）骨科手术,2例（7％）其他.所有AKI病例中急诊手术达15例.单因素分析提示高血压,低蛋白血症,术前应用ACEI或ARB类药物、术中低血压、输血、急诊手术可能与术后AKI有关（P＜0.05）.多因素Logistic回归分析显示术中低血压,术前应用ACEI或ARB类药物,低蛋白血症,急诊手术为术后发生AKI的危险因素. 结论 AKI在非心血管手术的发病率并不罕见.发生AKI的手术种类多为干扰到全身血流动力学、对内环境影响较大的手术.术中低血压、术前应用ACEI或ARB类药物、低蛋白血症、急诊手术可作为非心血管手术术后发生AKI的预警因素.

Objective To investigate the incidence of acute kidney injury （AKI） after noncardiac surgery and evaluate the risk factors of postoperative AKI using a nested case-control design.Methods We conducted a retrospective study of 19 132 patients who underwent noncardiac surgery from Jan 2012 to Oct 2014,among which 28 cases could be diagnosed with AKI which occurred postoperatively.168 cases with similar surgical types,date of operation and anesthesia technique were explored as control group according to the principle of the nested case-control design.Postoperative AKI was defined by serum creatinine change,as per the kidney disease improving global outcomes （KDIGO） guideline.The possible risk factors for postoperative AKI were evaluated including age,sex,BMI,hypertension,diabetes,preoperative use of angiotensin converting enzyme inhibitors （ACEI） or angiotensin receptor blockers（ARB）,hypoalbuminemia and intraoperative hypotension.Results Of the 19 132 patients,28（0.146%） developed AKI.Among the 28 cases,14 （50%） cases were gastrointestinal surgery,6 （22%） cases were abdominal organs surgery,2 （7%） cases were gynecological surgery,2 （7%） cases were urology surgery,2 （7%） cases were orthopaedic surgery,and 2 （7%） cases were other surgery.15 cases were emergency in total.Univariate analysis showed that hypertension,hypoalbuminemia,preoperative use of ACEI or ARB,intraoperative hypotension,blood transfusion and emergency surgery were possibly relative to postoperative AKI （P〈0.05）.Logistic regression analysis further revealed that intraoperative hypotension,preoperative use of ACEI or ARB,hypoalbuminemia and emergency surgery were risk factors for AKI after noncardiac surgery.Conclusions AKI is not uncommon after noncardiac surgery.The surgeries that tend to develop AKI are those which have interrupted the haemodynamics and influenced the homeostasis of the patients.Intraoperative hypotension,preoperative use of ACEI or ARB,hypoalbuminemia and emergency surgery are independent predictors for AKI after noncardiac surgery.