先天性心脏病小儿术后急性肾损伤的临床危险因素分析

Clinically relevant risk factors for acute kidney injury after pediatric congenital heart surgery

目的探讨<4岁先天性心脏病小儿术后发生急性肾损伤(acute kidney injury,AKI)的临床危险因素。方法收集2015年4月至2016年4月在新桥医院行先天性心脏病手术治疗的<4岁患儿临床资料,以改良儿童肾脏疾病风险分级(pediatric risk injury failure loss and end stage kidney diseases,pRIFLE)作为AKI诊断标准,分析术后AKI发生率,比较术后发生AKI(AKI组)与未发生AKI(N-AKI组)患儿的差异,并利用多因素Logistic回归分析筛选小儿先天性心脏病术后发生AKI的临床危险因素。结果共纳入298例患儿,其中男性152例,女性146例。107例(35.91%)患儿术后发生AKI,其中危险期82例(27.52%),损伤期16例(5.37%),衰竭期9例(3.02%)。与N-AKI组相比,AKI组患儿平均年龄、身高、体质量更低,术前合并紫绀及其他重要疾病概率更高,血清肌酐(serum creatinine,Scr)更低,ASA分级更高;手术时间、体外循环(cardiac pulmonary bypass,CPB)时间、主动脉钳闭时间(aortic clamping time,ACT)更长;术后尿素、尿酸、Scr、胱抑素、视黄醇结合蛋白更高,肌酐清除率(estimated creatinine clearance,eCCl)更低,住院时间更长,死亡率更高。其中年龄<1岁、术前合并紫绀、术前Scr低、手术时间较长是术后发生AKI的独立危险因素。结论年龄<1岁、术前合并紫绀、术前Scr低、手术时间较长会显著增加小儿先天性心脏病术后AKI发生风险。

Objective To investigate the risk factors for acute kidney injury （AKI） in children aged 〈 4 years old following congenital heart surgery. Methods Clinical data of pediatric patients （younger than 4 years old） undergoing congenital heart surgery in our hospital from April 2015 to April 2016 were collected. The modified criteria of pediatric risk, injury, and failure, and loss, and end-stage kidney disease （pRIFLE） were used to detect the incidence of AKI. The differences between the children with AKI and without were analyzed. Multivariate logistic regression analysis was employed to study the risk factors of AKI following congenital heart surgery. Results Of the 298 patients subjected, there were 152 boys and 146 girls. The incidence of AKI accounted for 35.91% （107 cases）, and 82 children （27.52%） attained at risk stage, 16 （5.37%） at injury stage, and 9 （3.02%） at failure stage. Compared with the children without AKI, those with AKI had younger age, shorter height, lower weight and lower Scr pre-operatively, but more complications of preoperative cyanosis and comorbidities, higher class in American Society of Anesthesiologists （ASA） physical status classification system, longer duration of surgery, cardiac pulmonary bypass （CPB） time, and aortic clamping time （ACT）. They also had higher levels of urea, uric acid, serum creatinine （Scr）,cystatin-C and retinol-binding protein, but lower estimated creatinine clearance （eCC1） , longer hospital stay and higher mortality after surgery. Logistic regression analysis showed that younger than 1 year old, cynosis, lower pre-operative Scr, and longer duration of surgery were independent risk factors for AKI. Conclusion Younger than 1 year old, complication of cynosis, lower pre-operative Scr, and longer duration of surgery significantly increase the incidence of AKI after congenital heart surgery.