原位心脏移植术后并发急性肾损伤临床分析

Clinical analysis of acute kidney injury after orthotopic heart transplantation

目的分析原位心脏移植受者术后急性肾损伤(acute kidney injury,AKI)发生情况并总结相关防治经验。方法回顾性分析南京市第一医院2014年1月至2018年12月行原位心脏移植术的38例受者临床资料,根据2012年改善全球肾脏疾病预后组织发布的AKI诊断标准分为AKI组(21例)及对照组(17例),并对发生AKI的受者进行肾功能损伤分期。比较两组受者术后一般资料及预后转归。采用两独立样本t检验比较两组受者年龄,体表面积,体质指数,术前血清肌酐、肾小球滤过率、血红蛋白、血糖、肺动脉收缩压、左室射血分数、心输出量,术中心肺转流时间、主动脉阻断时间、尿量、输注晶体量/胶体量、手术时间,术后中心静脉压(CVP)、右心室直径、左室射血分数、24 h尿量以及机械通气时间、ICU停留时间和总住院时间。采用Fisher确切概率法比较两组受者性别、术前合并症以及术后28、90和180 d死亡比例。P<0.05为差异有统计学意义。结果38例受者中有21例(55.3%)术后7 d内发生AKI,其中AKI 1期15例,AKI 2期4例,AKI 3期2例。AKI组受者术前肺动脉收缩压为(60±18)mmHg(1 mmHg=0.133 kPa),高于对照组[(45±15)mmHg],差异有统计学意义(t=2.790,P<0.05)。截至2019年6月,所有受者随访时间为6~56个月。AKI组和对照组受者术后CVP、术后右心室直径和ICU停留时间分别为(12.1±4.1)和(9.3±2.8)mmHg、(26.1±2.7)和(23.7±2.4)mm、(10.0±9.4)和(5.2±1.6)d,差异均有统计学意义(t=2.365、2.829和2.038,P均<0.05)。经过治疗,15例AKI 1期受者中12例肾功能恢复正常,2例遗留慢性肾功能不全,1例因纵隔严重感染致多器官功能衰竭死亡。4例AKI 2期受者中3例肾功能恢复正常,1例遗留慢性肾功能不全。2例AKI 3期受者均对利尿剂反应不佳,最终1例心功能恢复,但遗留慢性肾功能不全,另1例因多器官功能衰竭死亡。结论AKI是心脏移植术后较为常见的并发症之一,但只要积极预防、及时诊断、有效处理,大部分受者肾功能可恢复。

Objective To analysis the incidence of acute kidney injury(AKI)in orthotopic heart transplantation recipients,and to summarize the experience of prevention and treatment.Methods The clinical data of 38 recipients undergoing orthotopic heart transplantation from January 2014 to December 2018 admitted to Nanjing First Hospital were retrospectively analyzed.Recipients were divided into AKI group(21 cases)and control group(17 cases)according to the Kidney Disease Improving Global Outcome criteria,and renal function damage staging was determined in those recipients with AKI.The general data and prognosis of the 2 groups were compared.Two independent sample t-test was used for continuous variables and Fisher′s exact probability method was used for categorical variables.P<0.05 was considered statistically significant.Results AKI occurred in 21 of the 38 recipients(55.3%)within 7 days after surgery,including 15 cases in AKI stage 1,4 cases in AKI stage 2,and 2 cases in AKI stage 3.The preoperative pulmonary systolic pressure was(60±18)mmHg(1 mmHg=0.133 kPa),significantly higher than those in the control group[(45±15)mmHg](t=2.790,P<0.05).Up to June 2019,all the recipients were followed-up 6 to 56 months.The postoperative central venous pressure,postoperative right ventricular diameter and ICU stay in the AKI group were(12.1±4.1)mmHg,(26.1±2.7)mm and(10.0±9.4)days,respectively,greater than those in control group[(9.3±2.8)mmHg,(23.7±2.4)mm and(5.2±1.6)days,respectively],the differences were all statistically significant(t=2.365,2.829 and 2.038,P all<0.05).After treatment,12 recipients in AKI stage 1 returned to normal renal function,two recipients developed to chronic renal insufficiency,and one recipient died of multiple organ failure due to severe mediastinal infection.Three recipients in AKI stage 2 returned to normal renal function,one recipient developed to chronic renal insufficiency.Two recipients in AKI stage 3 all responded poorly to diuretics.In the end,one recipient recovered heart function,but remained with chronic renal insufficiency,and another one died of multiple organ failure.Conclusions AKI is one of the most common complications among heart transplant recipients,but with active prevention,timely diagnosis,and effective treatment,the renal function of the majority recipients with renal impairment can return to normal.