原位肝移植术后急性肾损伤发生的危险因素分析

Risk factor analysis of acute kidney injury after orthotopic liver transplantation

目的：探讨原位肝移植术后急性肾损伤发生的危险因素及预后。方法：采用回顾性病例对照研究方法。收集2013年1月至2015年12月西安交通大学第一附属医院收治的127例行原位肝移植受者的临床资料。127例受者中，24例术后发生急性肾损伤，其中1级、2级、3级分别为17、5、2例；103例术后未发生急性肾损伤。原位肝移植术后急性肾损伤处理方法依据改善全世界肾脏疾病预后组织（KDIGO）2012年指南。观察指标：（1）原位肝移植术后急性肾损伤发生的危险因素分析。（2）不同急性肾损伤分级受者术后恢复情况比较。（3）随访和生存情况。采用门诊和电话方式进行随访，随访时间截至2017年7月。正态分布计量资料以±s表示，偏态分布计量资料以M（范围）表示，单因素分析分别采用t检验和秩和检验。计数资料比较和单因素分析均采用x2检验或Fisher确切概率法。多因素分析采用logistic回归模型。采用Kaplan-Meier法计算生存率和绘制生存曲线，采用Log-rank检验进行生存分析。结果：（1）原位肝移植术后急性肾损伤发生的危险因素分析。单因素分析结果显示：受者的年龄、合并高血压病、术前肝功能Child评分、术前终末期肝病模型评分、术前血红蛋白、术前血清白蛋白、术前血尿素氮、术前肾小球滤过率、术前凝血酶原时间、手术时间、下腔静脉阻断时间、无肝期时间、术中出血量、术中总输血量、术中输血浆量、术中输红细胞量、术中腹腔引流量、术后ICU住院时间、术后使用血管活性药物、术后机械通气时间、术后发生感染，供者的体质量指数、供肝冷缺血时间是影响原位肝移植受者术后急性肾损伤发生的相关因素（t=4.154， x2=8.482，t=5.129，3.694，1.294，9.223，5.418，Z=4.287，t=2.105，5.168，8.182，10.042，Z=1.074，0.664，6.274，3.712，1.289，t=1.056， x2=10.617，t=2.447，3.371，1.476，P〈0.05）。多因素分析结果显示：受者的年龄、术前终末期肝病模型评分、术前血清白蛋白、术中出血量，供肝冷缺血时间是影响原位肝移植受者术后急性肾损伤发生的独立因素（优势比=0.812，0.866，1.392，1.001，0.516，95%可信区间：0.717～0.919，0.751～0.997，1.104～1.755，1.000～1.001，0.282～0.944，P〈0.05）。（2）不同急性肾损伤分级受者术后恢复情况比较：17例原位肝移植术后急性肾损伤1级受者中，完全恢复、部分恢复、慢性肾衰竭受者例数分别为14、3、0例，5例急性肾损伤2级受者上述恢复情况例数分别为3、2、0例，2例急性肾损伤3级受者上述恢复情况例数分别为0、1、1例。不同急性肾损伤分级受者术后恢复情况比较，差异有统计学意义（x2=14.140，P〈0.05）。（3）随访和生存情况：127例受者均获得术后随访，随访时间为9～44个月，中位随访时间为23个月。127例受者术后1年总体生存率为95.3%。随访期间，22例受者死亡，其中多器官衰竭9例、原发疾病复发8例、呼吸系统并发症5例。24例原位肝移植术后急性肾损伤受者与103例未发生急性肾损伤受者中位总体生存时间分别为36个月和40个月，两者比较，差异无统计学意义（x2=3.033，P〉0.05）。结论：受者的年龄、术前终末期肝病模型评分、术前血清白蛋白、术中出血量，供肝冷缺血时间是影响原位肝移植受者术后急性肾损伤发生的独立因素；急性肾损伤1级受者恢复更好。

Objective：To investigate the risk factors and prognosis of acute kidney injury （AKI） after orthotopic liver transplantation （OLT）. Methods：The retrospective case-control study was conducted. The clinical data of 127 patients who underwent OLT in the First Affiliated Hospital of Xi′an Jiaotong University from January 2013 to December 2015 were collected. Of 127 patients, 24 were complicated with postoperative AKI, including 17 in grade 1, 5 in grade 2 and 2 in grade 3, and 103 were not complicated with AKI. AKI after OLT was treated according to the diagnostic criteria of AKI from 2012 guidelines of Kidney Disease： Improving Global Outcomes （KDIGO）. Observation indicators： （1） risk factors analysis affecting AKI after OLT; （2） comparison of postoperative recovery in patients with different AKI grade; （3） follow-up and survival situations. Follow-up using outpatient examination and telephone interview was performed up to July 2017. Measurement data with normal distribution were represented as ±s, and measurement data with skewed distribution were described as M （range）. Univariate analysis was done using the t test and rank sum test. Comparisons of count data and univariate analysis were done using chi-square test or Fisher exact probability. Multivariate analysis was done using the logistic regression model. The survival rate and curve were respectively calculated and drawn by the Kaplan-Meier method, and Log-rank test was used for survival analysis. Results：（1） Risk factors analysis affecting AKI after OLT： results of univariate analysis showed that age, combined hypertension, preoperative Child-Pugh score, preoperative model for end-stage liver disease score （MELD）, preoperative hemoglobin, preoperative serum albumin, preoperative blood urea nitrogen, preoperative glomerular filtration rate, preoperative prothrombin time, operation time, inferior vena cava occlusion time, duration of anhepatic phase, volume of intraoperative blood loss, total volume of intraoperative blood transfusion, volumes of intraoperative plasma and red blood cells transfusion, duration of postoperative ICU stay, use time of postoperative vasoactive drugs, time of postoperative mechanical ventilation, cases with postoperative infection, body mass index of donor and donor liver cold-ischemia time were related factors affecting occurrence of AKI after OLT （t=4.154, x2= 8.482, t=5.129, 3.694, 1.294, 9.223, 5.418, Z=4.287, t=2.105, 5.168, 8.182, 10.042, Z=1.074, 0.664, 6.274, 3.712, 1.289, t=1.056, x2=10.617, t=2.447, 3.371, 1.476, P〈0.05）. Results of multivariate analysis showed that age, preoperative MELD score, preoperative serum albumin, volume of intraoperative blood loss and donor liver cold-ischemia time were independent factors affecting occurrence of AKI after OLT [odds ratio （OR） =0.812, 0.866, 1.392, 1.001, 0.516, 95% confidence interval： 0.717-0.919, 0.751-0.997, 1.104-1.755, 1.000-1.001, 0.282-0.944, P〈0.05]. （2） Comparison of postoperative recovery in patients with different AKI grade： cases with complete recovery, partial recovery and chronic renal failure were respectively 14, 3, 0 in 17 patients with grade 1 of AKI and 3, 2, 0 in 5 patients with grade 2 of AKI and 0, 1, 1 in 2 patients with grade 3 of AKI, with a statistically significant difference （x2=14.140, P〈0.05）. （3） Follow-up and survival situations： 127 patients were followed up for 9-44 months, with a median of 23 months. The 1-year overall survival rate of 127 patients was 95.3%. During the follow-up, 22 patients died, including 9 with multiple organ failure, 8 with primary disease recurrence and 5 with respiratory complication. The median overall survival time after OLT was 36 months in 24 patients with AKI and 40 months in 103 patients without AKI, with no statistically significant difference （x2=3.033, P〉0.05）. Conclusions：Age, preoperative MELD score, preoperative serum albumin, volume of intraoperative blood loss and donor liver cold-ischemia time are independent factors affecting occurrence of AKI after OLT, and there is better recovery in patients with grade 1 of AKI.