血红蛋白水平对急性心肌梗死患者发生急性肾损伤风险的影响

Effects of hemoglobin level on the risk of acute kidney injury in patients with acute myocardial infarction

目的观察急性心肌梗死(AMI)患者术前血红蛋白(Hb)水平对经皮冠状动脉介入治疗(PCI)后发生急性肾损伤(AKI)风险的影响。方法采用回顾性研究方法。选择2015年5月至2020年5月在南京医科大学附属常州市第二人民医院心血管内科住院的接受PCI的AMI患者作为研究对象。根据PCI前后血肌酐(SCr)水平将患者分为AKI组和非AKI组。比较是否发生AKI两组患者Hb水平的差异;采用单因素和多因素Logistic回归分析Hb水平对AMI患者行PCI后发生AKI风险的影响;采用Kaplan-Meier生存曲线评价Hb水平对AMI患者发生院内全因死亡的影响。结果共入选接受PCI的AMI患者922例, 其中165例(17.9%)发生了AKI。与非AKI组比较, AKI组患者女性比例较高〔35.8%(59/165)比26.9%(204/757)〕, 年龄更大(岁:69.78±14.56比66.61±13.44), 吸烟比例更低〔42.4%(70/165)比51.7%(391/757)〕, 合并高血压比例更高〔73.3%(121/165)比63.5%(481/757)〕, 心功能更差〔Killip分级≥3级患者比例更高, 33.9%(56/165)比13.9%(105/757)〕, Hb水平更低(g/L:127.61±22.18比132.79±19.45),使用血管紧张素转化酶抑制剂/血管紧张素Ⅱ受体拮抗剂(ACEI/ARB)类药物比例更低〔60.0%(99/165)比74.5%(564/757)〕, 使用利尿剂类药物比例更高〔24.8%(41/165)比17.7%(134/757)〕, 差异均有统计学意义(均P<0.05)。而AKI组患者手术时间>60 min〔4.2%(7/165)比1.5%(11/757)〕、术中造影剂用量>100 mL〔16.4%(27/165)比3.6%(27/757)〕、术中出现低血压〔16.4% (27/165)比8.2%(62/757)〕和植入≥2枚支架〔8.5%(14/165)比3.6%(27/757)〕的患者比例均较非AKI组更高(均P<0.05)。单因素回归分析显示, 术前Hb水平每升高1 g/L, 术后AKI风险下降1.2% 〔优势比(OR)=0.988, 95%可信区间(95%CI)为0.980~0.996, P=0.003〕;而术前Hb水平每升高1个标准差, 术后AKI风险则下降22.1%(OR=0.779, 95%CI为0.661~0.918, P=0.003)。将患者再按Hb水平分为低、中、高3个浓度组(Hb水平分别为<110 g/L、110~150 g/L、≥150 g/L), 多因素Logistic回归分析显示, Hb高浓度组患者术后AKI发生风险较低浓度组患者明显降低(OR=0.463, 95%CI为0.241~0.888, P=0.020)。Kaplan-Meier生存曲线提示, Hb低浓度组患者AMI后短期生存率较中、高浓度组患者明显降低(Log-Rank:χ2=23.215, P<0.001)。结论术前低Hb水平是AMI患者术后发生AKI风险的独立危险因素, 低Hb水平的AMI患者梗死后1个月内全因死亡风险升高。

Objective To investigate the effect of preoperative hemoglobin(Hb)level on the risk of developing acute kidney injury(AKI)after percutaneous coronary intervention(PCI)in patients with acute myocardial infarction(AMI).Methods A retrospective study was conducted.The hospitalized patients diagnosed with AMI who underwent PCI from May 2015 to May 2020 in the department of cardiology in the Affiliated Changzhou No.2 People's Hospital of Nanjing Medical University were enrolled.According to the serum creatinine(SCr)level before and after interventional therapy,the patients were divided into an AKI group and a non-AKI group.The difference in patients'Hb levels between the AKI and non-AKI groups was compared.Univariate and multivariate Logistic regression analyses were used to analyze the effects of Hb levels on the risk of AKI after interventional therapy in patients with AMI.Kaplan-Meier survival curve was used to evaluate the effects of Hb levels on patients with AMI in all-cause death in the hospital.Results A total of 922 AMI patients were enrolled in this study,of which 165 patients(17.9%)developed AKI.Compared with the non-AKI group,female patients in the AKI group had a higher proportion[35.8%(59/165)vs.26.9%(204/757)],older(age:69.78±14.56 vs.66.61±13.44),with a lower rate of smoking[42.4%(70/165)vs.51.7%(391/757)]and a higher prevalence of hypertension[73.3%(121/165)vs.63.5%(481/757)],however,the patients in AKI group also had a worse cardiac function[the proportion of Killip grade 3 or above was higher:33.9%(56/165)vs.13.9%(105/757)],lower Hb level(g/L:127.61±22.18 vs.132.79±19.45),and there were less patients using angiotensin converting enzyme inhibitor/angiotensinⅡreceptor blocker[ACEI/ARB,60.0%(99/165)vs.74.5%(564/757)]and more patients using diuretics[24.8%(41/165)vs.17.7%(134/757)]in AKI group,the differences were statistically significant(all P<0.05).Compared with non-AKI group,patients in AKI group had a longer operation time[operation time>60 minutes:4.2%(7/165)vs.1.5%(11/757)]and received more contrast media during the operative procedure[contrast media>100 mL:16.4%(27/165)vs.3.6%(27/757)],the individuals had a higher rate of intra-operative hypotension[16.4%(27/165)vs.8.2%(62/757)],and more patients were implanted more than 2 stents[8.5%(14/165)vs.3.6%(27/757),all P<0.05].Univariate Logistic regression analysis suggested that each 1 g/L increase in preoperative Hb level was associated with a 1.2%decrease in the risk of postoperative AKI[odds ratio(OR)=0.988,95%confidence interval(95%CI)was 0.980-0.996,P=0.003].Meanwhile,for every 1 standard deviation increase in preoperative Hb level,the risk of postoperative AKI decreased by 22.1%(OR=0.779,95%CI was 0.661-0.918,P=0.003).The patients were divided into low,medium and high concentration groups according to Hb levels(Hb levels were<110 g/L,110-150 g/L,≥150 g/L,respectively),and multivariate Logistic regression analysis showed that the risk of AKI was significantly reduced in the high concentration group compared with that in the low concentration group(OR=0.463,95%CI was 0.241-0.888,P=0.020).The Kaplan-Meier survival curve analysis indicated that the short term survival after coronary intervention in AMI patients with low Hb concentration was significantly lower than that in patients with medium and high Hb concentration(Log-Rank:χ2=23.215,P<0.001).Conclusions Preoperative lower Hb level is an independent risk factor for postoperative AKI in AMI patients.AMI patients with lower Hb levels have an increased risk of all-cause mortality within 1 month after AMI.