中心静脉压峰值与体外循环心脏术后急性肾损伤的相关性

Peak Value of Central Venous Pressure and Acute Kidney Injury in Cardiac Patients After Cardiopulmonary Bypass Surgery

目的探究体外循环心脏手术(cardiopulmonary bypass surgery,CBS)后中心静脉压峰值(peak value of central venous pressure,CVPp)与急性肾损伤(acute kidney injury,AKI)的关系。方法回顾性收集2016年5月1日至2018年5月1日北京协和医院重症医学科所有CBS患者的临床资料。记录转入ICU后即刻中心静脉压(central venous pressure,CVP)(CVP 0h)、6 h时CVP(CVP 6h),转入ICU 48 h内CVPp(CVPp 48h),以及转入ICU 48 h后AKI发生率及院内死亡率。采用受试者操作特征(receiver operating characteristic,ROC)曲线评估CVP相关指标预测CBS术后发生AKI的临床价值并确定最佳临界值;采用单因素与多因素Logistic回归分析CBS术后发生AKI、院内死亡的危险因素。结果共入选符合纳入和排除标准的CBS患者485例,AKI发生率为25.2%(122/485),院内死亡率为2.5%(12/485)。ROC曲线分析显示,CVPp 48h预测CBS术后发生AKI的曲线下面积(area under the curve,AUC)为0.634(95%CI:0.577~0.692,P<0.001),最佳临界值为14 mm Hg,灵敏度为49.6%,特异度为63.5%。多因素Logistic回归分析显示,高血压(OR=2.505,95%CI:1.581~3.969,P<0.001)、肺动脉高压(OR=2.552,95%CI:1.573~4.412,P<0.001)、主动脉阻断时间延长(OR=1.009,95%CI:1.004~1.014,P=0.001)、CVPp 48h≥14 mm Hg(OR=1.613,95%CI:1.030~2.526,P=0.037)是CBS术后发生AKI的独立危险因素;CVPp 48h≥14 mm Hg是院内死亡的独立危险因素(OR=8.044,95%CI:1.579~40.979,P=0.012)。结论CVPp 48h升高可能增加CBS术后AKI发生风险,对其动态监测有助于AKI的预防和早期识别。

Objective To explore the relationship between the post-operative peak value of central venous pressure(CVPp)and the incidence of acute kidney injury(AKI)in patients who had undergonecardiopulmonary bypass surgery(CBS).Methods Clinical data were retrospectively collected from 1 May 2016 to 1 May 2018 from all patients undergoing CBS in the Department of Intensive Care Medicine,Peking Union Medical College Hospital.The CVP values immediately after transfer to ICU(CVP 0 h)and at 6 h(CVP 6 h),and CVPp within 48 h(CVPp 48 h)of transfer to ICU,the incidence of AKI after 48 h of transfer to ICU and in-hospital mortality were recorded.The receiver operating characteristic(ROC)curve was used to evaluate the clinical value of CVP-related indicators in predicting AKI after CBS and determine the optimal threshold.The risk factors for AKI and in-hospital mortality after CBS were analysed using single factor and multifactorial Logistic regression.Results A total of 485 patients after CBS who met the inclusion and exclusion criteria were enrolled,with an incidence of AKI after 48 h of transfer to ICU of 25.2%(122/485)and an in-hospital mortality rate of 2.5%(12/485).The ROC curve analysis showed that the area under the curve(AUC)for CVPp 48 h to predict AKI after CBS was 0.634(95%CI:0.577-0.692,P<0.001),with an optimal threshold value of 14 mm Hg,sensitivity of 49.6%and specificity of 63.5%.Multifactorial logistic regression analysis showed that hypertension(OR=2.505,95%CI:1.581-3.969,P<0.001),pulmonary hyperten-sion(OR=2.552,95%CI:1.573-4.412,P<0.001),prolonged aortic block time(OR=1.009,95%CI:1.004-1.014,P=0.001),and CVPp 48 h≥14 mm Hg(OR=1.613,95%CI:1.030-2.526,P=0.037)were independent risk factors for AKI after CBS;CVPp 48 h≥14 mm Hg was an independent risk factor for in-hospital death(OR=8.044,95%CI:1.579-40.979,P=0.012).Conclusions CVPp 48 h is associated with AKI in patients who have undergone CBS.The monitoring and management of CVP might be a way to improve the prognosis of these patients.