急性StanfordA型主动脉夹层术后中重度急性肾损伤、院内死亡及透析依赖的危险因素分析

Risk Factors for Moderate-severe Acute Kidney Injury,In-hospital Mortality and Dialysis Dependence After Acute Stanford Type A Aortic Dissection Surgery

目的:探究急性Stanford A型主动脉夹层术后发生中重度急性肾损伤(AKI)、院内死亡及透析依赖的危险因素。方法:回顾性连续纳入2014年12月至2016年12月在中国医学科学院阜外医院行升主动脉置换、全主动脉弓置换术联合支架象鼻手术、发病距就诊时间<14 d且资料完整的急性Stanford A型主动脉夹层患者294例。根据改善全球肾脏病预后组织(KDIGO)2012年标准进行AKI的诊断和分期,AKI 2或3期为中重度AKI,未发生AKI及AKI 1期为非中重度AKI。根据术后是否发生AKI及AKI的严重程度分为非中重度AKI组(n=186)和中重度AKI组(n=108)。采用多因素Logistic回归分析术后发生中重度AKI、院内死亡或出院时透析依赖的危险因素。结果:术后AKI 1期、AKI 2期、AKI 3期的发生率分别为42.2%(124/294)、15.3%(45/294)、21.4%(63/294),总AKI发生率为79.3%(232/294)。需肾脏替代治疗(CRRT)的患者比例为9.2%(27/294)。出院时透析依赖的患者比例为3.1%(9/294),院内死亡率为3.7%(11/294)。与非中重度AKI组相比,中重度AKI组合并高血压(79.6%vs.88.9%,P=0.040)、术前肾灌注减低的患者比例(7.0%vs.24.1%,P<0.001)均较高,术中体外循环时间[(161.6±34.0)min vs.(192.2±61.1)min,P<0.001]、主动脉阻断时间[(90.4±22.1)minvs.(104.3±29.5)min,P<0.001]均更长,术中超滤量更多[4000(3000,5000)mlvs.5000(4000,6262)ml,P<0.001]。多因素Logistic回归分析显示,术前肾灌注减低(OR=4.95,95%Cl:1.97~12.26,P<0.001)、体外循环时间延长(OR=1.01,95%Cl:1.00~1.02,P=0.016)为急性StanfordA型主动脉夹层术后发生中重度AKI的独立危险因素。进一步分析发现,体外循环时间延长(OR=1.02,95%Cl:1.01~1.03,P=0.007)和中重度AKI(OR=10.49,95%Cl:1.22~90.62,P=0.033)是院内死亡或出院时透析依赖的独立危险因素。结论:术前肾灌注减低、体外循环时间延长是急性Stanford A型主动脉夹层术后发生中重度急性肾损伤的独立危险因素。体外循环时间延长和中重度AKI明显增加院内死亡及出院时透析依赖的风险,因此,对此类患者需要进行密切关注随访。

Objectives:This study was aimed to investigate the risk factors for moderate and severe acute kidney injury(AKI),inhospital mortality and dialysis dependence after acute Stanford type A aortic dissection(TAAD)surgery.Methods:Complete clinical data of 294 TAAD patients who underwent ascending aorta replacement,total aortic arch replacement combined with frozen elephant trunk between December 2014 and December 2016 with time between symptom onset and diagnosis<14 days were retrospectively and consecutively collected and analyzed.AKI was defined according to the SCr component of the Kidney Disease Improving Global Outcomes(KDIGO)2012 consensus criteria,and classified as moderate-severe AKI(AKI stage 2-3)or non-moderate-severe AKI(no AKI or AKI stage 1).Univariate and multivariate logistic regression analyses were used to analyze the risk factors for moderate to severe AKI,in-hospital mortality or dialysis dependence after TAAD surgery.Results:AKI occurs in 232 out of 294 patients(79.3%),124(42.2%)with AKI stage 1,45(15.3%)with AKI stage 2,63(21.4%)with AKI stage 3,and 27(9.2%)requiring continuous renal replacement therapy(CRRT).The dialysis dependence rate at discharge was 3.1%(n=9),and overall in-hospital mortality rate was 3.7%(n=11).Univariate analysis revealed that patients who developed the moderate-severe AKI were more likely to present with hypertension,preoperative renal hypoperfusion,longer duration of cardiopulmonary bypass(CPB),longer duration of aortic cross-clamp and higher intraoperative ultrafiltration volume(all P<0.05).Multivariate logistic regression analysis showed that renal hypoperfusion(OR=4.95,95%CI:1.97-12.26,P<0.001),and prolonged CPB time(OR=1.01,95%CI:1.00-1.02,P=0.016)were independent risk factors for moderate-severe AKI after TAAD surgery.Further analysis revealed that prolonged CPB time(OR=1.02,95%Cl:1.01-1.03,P=0.007)and moderate-severe AKI(OR=10.49,95%Cl:1.22-90.62,P=0.033)were independent risk factors for in-hospital mortality or dialysis dependence after TAAD surgery.Conclusions:Preoperative renal hypoperfusion and prolonged CPB time are independent risk factors for moderatesevere AKI after TAAD surgery.Prolonged CPB time and occurrence of moderate to severe AKI significantly increase the risk of in-hospital mortality and dialysis dependence,indicating that close clinical follow-up of these patients is required.