深低温停循环手术后急性肾损伤的临床研究

Clinical study of acute renal injury after deep hypothermic circulatory arrest

目的探究深低温停循环(deep hypothermic circulatory arrest,DHCA)术后急性肾损伤(acute kidney injury,AKI)的发病情况,探讨术后发生AKI的相关危险因素及患者预后情况,建立相对准确的术前风险评估策略及防治措施。方法回顾性分析2014年1月至2018年10月在我院心脏外科行DHCA手术252例患者的临床资料,其中男179例、女73例,平均年龄(53.6±11.6)岁。采用改善全球肾脏疾病预后组织(kidney disease improving global outcomes,KDIGO)的AKI诊断标准,将患者分为AKI组和非AKI组,比较两组资料,并采用单因素及多因素logistic回归分析DHCA术后AKI发生的相关危险因素。结果入选的252例患者中,AKI的发病率为69.0%;术后住院死亡率为7.9%(20/252)。单因素分析结果显示:患者年龄、体重指数(body mass index,BMI)≥28 kg/m^2、左室射血分数<55%、术前血清肌酐值(serum creatinine,Scr)≥110μmol/L、术前估计肾小球滤过率(estimated glomerular filtration rate,eGFR)、Cleveland评分分值及术中体外循环时间、术中输注红细胞、术中输注血浆、术后机械通气时间≥40 h等指标在两组患者中的差异有统计学意义(P<0.05);多因素logistic回归分析结果显示:患者年龄[OR=1.040,95%CI(1.017,1.064),P=0.001]、BMI≥28 kg/m^2[OR=2.335,95%CI(1.093,4.990),P=0.029]、eGFR<90 mL/(min·1.73 m^2)[OR=2.044,95%CI(1.082,3.863),P=0.028]、术前Cleveland评分[OR=1.300,95%CI(1.054,1.604),P=0.014]、术中体外循环时间[OR=1.009,95%CI(1.002,1.017),P=0.014]在两组间的差异有统计学意义。结论 DHCA术后AKI的发生率较高,术后发生AKI的患者住院时间较长、住院死亡风险明显增高;患者年龄、BMI≥28 kg/m^2、eGFR<90 mL/(min·1.73 m^2)、术前Cleveland评分、术中体外循环时间为DHCA术后并发AKI的独立危险因素。

Objective To investigate the incidence of acute kidney injury(AKI) after deep hypothermic circulatory arrest(DHCA), to explore the risk factors and prognosis of postoperative AKI, and to establish a relatively accurate preoperative risk assessment strategy and prevention measures. Methods The clinical data of 252 patients who underwent deep hypothermic circulatory surgery in our hospital from January 2014 to October 2018 were retrospectively analyzed. There were 179 males and 73 females with an average age of 53.6±11.6 years. The patients were divided into an AKI group and a non-AKI group according to the AKI diagnostic criteria developed by kidney disease improving global outcomes(KDIGO). The data of the two groups were compared, and the risk factors related to AKI after DHCA were analyzed by single factor and multivariate logistic regression. Results Among the 252 patients enrolled, the incidence of AKI was 69.0%. The postoperative hospital mortality rate was 7.9%(20/252). The univariate analysis showed that the patient’s age and body mass index(BMI)≥28 kg/m^2, left ventricular ejection fraction<55%, preoperative serum creatinine(Scr)≥110 μmol/L, preoperative estimated glomerular filtration rate(eGFR), Cleveland score and intraoperative cardiopulmonary bypass time, intraoperative infusion of red blood cells, intraoperative infusion of plasma, postoperative mechanical ventilation time≥40 h and other indicators were significantly different between the two groups(P<0.05);multivariate logistic regression analysis showed that there was significant difference between the two groups in age(OR=1.040, 95% CI 1.017–1.064, P=0.001), BMI≥28 kg/m^2(OR=2.335, 95%CI 1.093–4.990, P=0.029), eGFR<90 mL/(min·1.73 m^2)(OR=2.044, 95%CI 1.082–3.863, P=0.028), preoperative Cleveland score(OR=1.300, 95%CI1.054–1.604, P=0.014) and intraoperative cardiopulmonary bypass time(OR=1.009, 95%CI 1.002–1.017, P=0.014).Conclusion The incidence of AKI is higher after DHCA. Patients with postoperative AKI have longer hospital stay and higher risk of hospitalization death. The age of patients, BMI≥28 kg/m^2, eGFR<90 mL/(min·1.73) m^2, Cleveland score,intraoperative extracorporeal circulation time are independent risk factors for AKI after DHCA.