体外膜肺氧合辅助心肺复苏治疗急性心肌梗死的主要肾脏不良事件

The major adverse kidney events in acute myocardial infarction with extracorporeal cardiopulmonary resuscitation

目的调查体外膜肺氧合辅助心肺复苏(extracorporeal cardiopulmonary resuscitation,ECPR)治疗急性心肺梗死(acute myocardial infarction,AMI)的90 d主要肾脏不良事件(major adverse kidney events,MAKE)。方法回顾性分析南京医科大学第一附属医院急诊中心2015年4月至2023年4月75例AMI-ECPR的资料,以90 d存活/死亡、有/无RRT(renal replacement therapy)、是否AKI(acute kidney injury)原因启动RRT进行分组,比较年龄、性别、查尔森合并症指数、IHCA/OHCA(out-of-hospital/in-hospital cardiac arrest)、初始心律、Gensini评分、ECPR初始血气pH和乳酸值、无灌流时间、心脏骤停至ECMO(extracorporeal membrane oxygenation)转流时间(CA-Pump On时间)、ECMO和RRT治疗时间、90 d存活率等的差异,并随访幸存者的肾功能情况。结果①68例AMI-ECPR患者纳入分析,90 d存活22人(32.4%),共有54人(79.4%)联合RRT,90 d MAKE有48人(70.6%)。②与死亡组相比,90 d存活组初始可电击心律的比例高,Gensini评分低,且ECPR初始血气pH值高、乳酸值低。③RRT组冠状动脉病变、ECPR初始酸中毒和高乳酸血症的严重程度显著高于非RRT组,非RRT组悉数存活。④AKI-RRT组与非AKI-RRT组之间差异无统计学意义,21人AKI 1期启动RRT,存活5人,其中1人90 d仍需要RRT,7人AKI 2~3期启动RRT均死亡。结论AMI-ECPR患者90 d MAKE的发生率高达70.6%,合并AKI的AMI-ECPR幸存者90 d肾功能恢复不良率高达20.0%,积极启动RRT避免发生AKI或在AKI早期启动RRT,可能改善AMI-ECPR患者的预后。

Objective To investigate the major adverse kidney events(MAKE)in acute myocardial infarction(AMI)with extracorporeal cardiopulmonary resuscitation(ECPR).Methods The data of 75 patients with AMI-ECPR in Emergency Medicine Department of the First Affiliated Hospital of Nanjing Medical University from April 2015 to April 2023 were retrospectively analyzed.The patients were grouped by survival/death at 90 days,with/without renal replacement therapy(RRT),and whether to initiate RRT because of acute kidney injury(AKI).age,sex,Charlson comorbidity index,OHCA/IHCA(out-of-hospital/in-hospital cardiac arrest),initial rhythm,Gensini score,ECPR initial blood gas pH and lactate value,no-flow time,time from cardiac arrest to extracorporeal membrane oxygenation(ECMO)initiation(CA-Pump On time),ECMO and RRT treatment time,90-day survival rate were analyzed.Moreover,the renal function of the survivors was followed up.Results①Total of 68 AMI-ECPR patients were enrolled,22(32.4%)patients survived at 90 days,54(79.4%)combined with RRT,and 48(70.6%)MAKE within 90 days.②Compared with the death group,the 90-day survival group had a higher proportion of initial shockable heart rhythm,a lower Gensini score,a higher ECPR initial blood gas pH and a lower lactic acid value.③The severity of coronary artery disease,ECPR initial acidosis and hyperlactacemia in the RRT group was significantly higher than that in the non-RRT group,and all the non-RRT group patients survived.④There was no difference between the AKI-RRT group and the non-AKI-RRT group.Of 21 patients with stage 1 AKI initiating RRT,5 survived,one of them still needs RRT for 90 days,and 7 patients with stage 2 to 3 AKI initiating RRT died.Conclusions The 90-day MAKE rate in AMI-ECPR patients was as high as 70.6%,and the 90-day renal insufficiency rate in AMI-ECPR survivors with AKI was as high as 20.0%.Active initiation of RRT to avoid AKI or early initiation of RRT may improve the prognosis of AMI-ECPR patients.