同型半胱氨酸与心脏瓣膜置换术后急性肾损伤发生的关系

Correlation analysis between homocysteine level and acute kidney injury after cardiac valve replacement surgery

目的探讨术前血清同型半胱氨酸(homocysteine,Hcy)水平与心脏瓣膜置换术后急性肾损伤(acute kidney injury,AKI)发生的关系.方法回顾性分析于2015年1月1日至2017年12月31日在广西医科大学第一附属医院接受心脏瓣膜置换术、年龄≥18周岁、术前未进行肾脏替代治疗、术前血肌酐(Scr)<178μmol/L的非肾功能失代偿、术后48 h内存活并且术前测量过血清Hcy的患者的资料.将术后48 h内Scr升高超过26.5μmol/L(0.3 mg/dl)或7 d内Scr升高超过基线1.5倍的患者诊断为AKI,据此将患者分为AKI组和非AKI组.将各个AKI影响因素进行组间比较,再采用多因素Logistic回归分析AKI发生的独立影响因素;将血清Hcy水平与AKI发生率做Spearman相关分析,探讨两变量间的关系;将是否发生AKI和血清Hcy水平作为变量绘制受试者工作特征曲线(ROC),分析术前血清Hcy水平预测心脏瓣膜置换术后AKI发生的价值.结果本研究共纳入810例研究对象,其中男375例,女435例;年龄(50±11)岁(19~78岁).其中心脏瓣膜置换术后7 d内发生AKI患者共329例,发生率为40.6%,其中男性AKI发生率为45.9%,女性AKI发生率为36.1%.AKI组术前血清Hcy水平高于非AKI组[(15.74±4.55)μmol/L比(13.87±3.85)μmol/L,t=6.106,P<0.01].多因素Logistic回归分析显示年龄(OR=1.030,95%CI 1.014~1.045,P<0.001)、体外循环时间(OR=1.011,95%CI 1.007~1.016,P<0.001)、Scr(OR=1.014,95%CI 1.005~1.023,P=0.002)、血清Hcy(OR=1.059,95%CI 1.017~1.103,P=0.006)、高水平Hcy(>13.64μmol/L)(OR=1.465,95%CI 1.059~2.027,P=0.021)及中重度高同型半胱氨酸血症(HHcy,16≤Hcy≤100μmol/L)[以正常HHcy(Hcy<10μmol/L)为参照,OR=2.180,95%CI 1.245~3.816,P=0.006]是心脏瓣膜置换术后AKI发生的独立影响因素.Spearman相关分析结果显示术后AKI发生率随术前血清Hcy水平的升高而增加(rs=0.927,P<0.001).ROC曲线结果显示,术前血清Hcy水平预测心脏瓣膜置换术后AKI发生的曲线下面积为0.701,界值为13.64μmol/L,敏感度为61.3%,特异度为70.9%.结论术前血清Hcy水平是心脏瓣膜置换术后AKI发生的独立影响因素,术前血清Hcy水平越高,术后AKI的发生率越高.术前血清Hcy水平>13.64μmol/L者术后发生AKI的风险增高.

Objective To investigate the relationship between preoperative serum homocysteine(Hcy)level and acute kidney injury(AKI)after cardiac valve replacement surgery.Methods The data of the inpatients who accepted cardiac valve replacement surgery,age≥18 years,no renal replacement therapy before surgery,non-renal decompensation and preoperative serum creatinine(Scr)<178μmol/L,survival within 48 h after surgery,and with preoperative serum Hcy data in the First Affiliated Hospital of Guangxi Medical University from January 1,2015 to December 31,2017 was retrospectively analyzed.AKI was diagnosed in patients whose Scr increased more than 26.5μmol/L(0.3 mg/dl)within 48 hours or 1.5 times higher than baseline within 7 days after surgery.According to this,patients were divided into AKI group and non-AKI group,and the affecting factors for AKI were compared between the two groups.Multivariate logistic regression was used to analyze the independent influencing factors of AKI.The relationship between serum Hcy level and AKI incidence was analyzed by Spearman correlation analysis.Whether the AKI occurred and serum Hcy levels were used as variables to map the receiver operating characteristic curve(ROC),and was used to assess the value of preoperative serum Hcy level for predicting AKI after cardiac valve replacement surgery.Results A total of 810 subjects were included in the study,including 375 males and 435 females.They were(50±11)years old(19-78 years old).Among them,329 patients with AKI occurred within 7 days after heart valve replacement,and the incidence rate was 40.6%(male 45.9%,female 36.1%).The serum Hcy level in the AKI group was higher than that in the non-AKI group[(15.74±4.55)μmol/L vs(13.87±3.85)μmol/L,t=6.106,P<0.01].Multivariate logistic regression analysis showed age(OR=1.030,95%CI 1.014-1.045,P<0.001),extracorporeal circulation time(OR=1.011,95%CI 1.007-1.016,P<0.001),Scr(OR=1.014,95%CI 1.005-1.023,P=0.002),serum Hcy(OR=1.059,95%CI 1.017-1.103,P=0.006),high level of Hcy(>13.64μmol/L)(OR=1.465,95%CI 1.059-2.027,P=0.021)and moderate to severe hyperhomocystinemia(16≤Hcy≤100μmol/L)[with normal HHcy(Hcy<10μmol/L)as reference,OR=2.180,95%CI 1.245-3.816,P=0.006]were independent influencing factors of AKI after cardiac valve replacement surgery.Spearman correlation analysis showed that the incidence of postoperative AKI increased with the increase of preoperative serum Hcy level(rs=0.927,P<0.001).The results of ROC curve showed that the area under the curve of the preoperative serum Hcy level predicting AKI after heart valve replacement was 0.701,and the cutoff value was 13.64μmol/L,with the sensitivity 61.3%,specificity 70.9%.Conclusions Preoperative serum Hcy level is an influencing factor for AKI after cardiac valve replacement surgery.The higher the level of preoperative serum Hcy,the higher the incidence of AKI after cardiac valve replacement surgery.Patients with preoperative serum Hcy levels>13.64μmol/L have an increased risk of AKI after cardiac valve replacement surgery.