术前不同肾功能分级对急性A型夹层全主动脉弓替换术后结果的影响

Impact of preoperative renal function classification on outcomes of total arch replacement for acute type A aortic dissection

目的:分析术前不同肾功能分级对急性Stanford A型主动脉夹层患者全主动脉弓替换术后近期效果的影响,评估术后主要不良事件的危险因素。方法:回顾性分析2012年1月至2019年12月因急性Stanford A型主动脉夹层在我院行全主动脉弓替换的226例患者的临床资料,其中男146例,女80例;年龄(54.4±12.5)岁。按术前内生肌酐清除率(estimated glomerular ltration rate,eGFR)分为4组:肾功能正常组(eGFR≥90 ml·min^(-1)·1.73 m^(-2))68例,轻度肾功能不全组(eGFR 60~89 ml·min^(-1)·1.73 m^(-2))73例,中度肾功能不全组(eGFR 30~59 ml·min^(-1)·1.73 m^(-2))57例,重度肾功能不全组(eGFR<30 ml·min^(-1)·1.73 m^(-2))28例。Logistic回归分析术后死亡的独立危险因素,ROC曲线下面积用来评估eGFR预测术后血液透析的能效。结果:住院死亡24例(10.6%),主要并发症包括术后需要血液透析49例(21.7%),术后卒中19例(8.4%),气管切开15例(6.6%)。预测术后需要血液透析的eGFR最佳截点是36.5 ml·min^(-1)·1.73 m^(-2)(ROC曲线下面积0.793)。多因素回归分析发现术前血肌酐、eGFR<30 ml·min^(-1)·1.73 m^(-2)、术前神经系统和肠道灌注不足、术后卒中、血液透析是院内死亡的危险因素。结论:轻度以下肾功能不全患者接受全主动脉弓替换术安全、可行,术前肾功能不全是全弓替换术后血液透析的危险因素,eGFR是术后血液透析的有效预测因子。术前肾功能不全的严重程度与术后结果有明显相关性,在临床危险因素评估过程中应重点关注术前肾功能的评估。

Objective To analyse the effect of preoperative renal function classification on early outcomes for patients with acute type A aortic dissection(AAAD)and to estimate the risk factors of postoperative major adverse events.Methods From January 2012 to December 2019,226 patients with AAAD who underwent total arch replacement at our institution were retrospectively analysed,including 146 males and 80 females,aged(54.4±12.5)years old.Stages of preoperative renal function were defined as follows:Normal[estimated glomerular ltration rate(eGFR)≥90 ml·min^(-1)·1.73 m^(-2),68 cases],Mild(eGFR 60-89 ml·min^(-1)·1.73 m^(-2),73 cases);Moderate(eGFR 30-59 ml·min^(-1)·1.73 m^(-2),57 cases),Severe(eGFR<30 ml·min^(-1)·1.73 m^(-2),28 cases).The independent risk factors for postoperative death were analyzed by logistic regression analysis.The area under the receiver operating characteristic curve was used to assess the efficiency of eGFR for predicting the postoperative hemodialysis.Results In-hospital death occurred in 24(10.6%)cases.Major complications included postoperative hemodialysis in 49(21.7%)cases,stroke in 19(8.4%)cases and tracheotomy in 15(6.6%)cases.The best cut-off value of the eGFR for predicting postoperative hemodialysis was 36.5 ml·min^(-1)·1.73 m^(-2)(area under the receiver operating characteristic curve was 0.793).The following variables were found to be risk factors of in-hospital mortality in multivariate logistic regression analysis:serum creatinine,eGFR<30 ml·min^(-1)·1.73 m^(-2),neural malperfusion,bowel malperfusion,postoperative stroke and hemodialysis.Conclusion Total arch replacement can be safely performed in patients with AAAD and mild renal dysfunction.Preoperative renal dysfunction is a risk factor for postoperative hemodialysis,and eGFR is useful for predicting the requirement for hemodialysis after total arch replacement.The severity of preoperative renal dysfunction could greatly influence the outcomes after total arch replacement for AAAD.More importance should be attached to the assessment of preoperative renal function during clinical risk assessment.